Mobile Physio, Dietitian, OT, Drama Therapy and Exercise Physiology Referral Form

Not sure which service you need? Follow this link to understand more about the services we offer: https://southsidephysio.com.au/services/southside-physio/

CURRENT WAIT TIMES (regularly updated):

Physio	No wait, depending on availability and location.
Exercise Physiology (EP)	Two weeks wait, depending on availability and location.
Physio or EP	See above
Occupational Therapy	At capacity.
Dietitian	No wait
LDK Greenway Physio or AHA	No wait
LDK Greenway Classes	No wait
LDK Amberfield Physio or AHA	Starting from late October.
LDK Amberfield Classes	Starting form late October.
Drama Therapy	Limited capacity, depending on availability and location.
Remedial Massage	At capacity

Please note that all services referred to through this referral form are MOBILE SERVICES ONLY.

If you wish to engage in a Physiotherapy, Exercise Physiology or Dietitian service in in the clinic, please contact our Woden or Tuggeranong clinic for an appointment (please see southsidephysio.com.au for clinic contacts or use Clinic Referral Form (snapforms.com.au)

Are you: *

The ClientThe Referrer

Please provide as much relevant information as possible - Insufficient/ incomplete referral information requires follow up and may delay the booking of your client's/ your appointment.

Referrer's Details

Name of Referrer *

Referrer's Contact No. *

Email address of Referrer *

Referring Company Name, if applicable

Support Coordinator/Case manager (if applicable)

Client Information

First Name *

Last Name *

DOB *

Contact Phone Number *

Does the contact phone number belong to the client? *

YesNo

If no, who is the contact? *

Client Email Address

Home Address (room number if LDK) *

Postcode

Who does the participant live with? *

Emergency Contact Name and Number

Relationship to Emergency Contact

Additional Client Details

* Not all services are able to be covered by Workers Compensation, and each referral will reviewed on a case-by-case basis. Third Party fee schedules are required to match SSPG's fee schedules, including Workers Compensation.

NDIS Funding Period

Is your NDIS plan broken up into funding components (e.g. annual, quarterly, monthly) *

YesNo

Funding Period Schedule

Funding Period Start

Funding Period End

Months

Funding Amount

to

Please tell us the time frame of your funding components (e.g. annual, quarterly, monthly) and how much funding is available per funding component

NDIS Number (if applicable):

Plan Dates/STRC dates (if applicable):

Budget for service (NDIS/Home care packages):

Please provide STRC program dates:

Claim Number (for Workers Compensation ONLY):

Injury Date (for Workers Compensation ONLY):

Name of Insurance Company (for Workers Compensation ONLY):

GP Name and Clinic *

Case History and Expected Outcome

Diagnosis and brief case history

Has the client experienced repeated chest infections (2 or more within the last 6-12 months not related to flu/covid etc)?

Does the client cough on food or drinks at all meals?

Has the client experienced multiple choking episodes?

Does the client have an existing swallowing difficulty and their condition is deteriorating?

Patient Goals/Recommendations/Purpose of Referral *

Is this referral for a script for Oral Nutrition Supplements?

What is the earliest date the client can start sessions?

Risk Assement

Risks to our team:

These are questions we have to ask to ensure the safety of our team, participants/clients and patients. Please note any risks in the box below. Please consider these questions carefully.

Is there anything you would like to tell us regarding access to your house, parking, etc?

Will the client and the practitioner be the only people present during treatment?

Will all animals be prevented access to the front of the property or the parts where the practitioner will be? If NO, what animals will be present, and do they pose any risk to the practitioner?

Will everyone in the property refrain from smoking, drinking alcohol or using substances during the visit?

Does anyone in the property have a history of actual or threatened violent/aggressive behaviour?

Are there weapons in the home?

Is there a work area in the property where the practitioner can safely place equipment and work?

Is there stable mobile phone service/coverage?

Is there any risk of infection or illness?

Are there any mental health challenges or considerations we need to be aware of?

Are there any behaviour triggers we need to be aware of? If so, is there a behaviour plan in place?

Are there any cultural considerations you would like us to be aware of?

Are there any other risks we need to be aware of?

Please note any risks here relative to the questions above. Please write NO risks if none exist. *

Any other relevant medical history?

Accounts. Where do we send your invoices? Please provide best contact name, email address and phone number. *

If you (referrer) would like to discuss the appointment prior to the appointment date, please advise our Mobile team by filling out the field below. Please include your best contact details.

Do you have any other important information you would like to provide? (Family/social situation/ EPOA etc)

Please upload any supporting documents here (NDIS PLAN, STRC or HCP summary, medication list, or past medical history)

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