Referrals

Please note that Adjustability therapists cannot treat participants until the signed Consent and Service Agreement has been returned to admin@adjustability.com.au.
For non-electronic paperwork options, please call us on 0481 280 290.

Step 1/6

Participant Details

First Name

Last Name

Date of Birth

Phone Number

Email Address

Gender

Address

Living Arrangement

Emergency Contact or Next-of-kin

Name

Phone

Relationship

Is a translator/interpreter or communication aids required? If Y, details:

Step 2/6

Diagnosis and History

Impairment Category

Intellectual Cognitive Sensory Neurological Physical Psychosocial

PRIMARY DISABILITY (NDIS) / MEDICAL CONDITIONS

What is the REASON for the REFERRAL?

RELEVENT HISTORY (IF APPLICABLE)

Choose a file or drag & drop it here

Please attach relevant reports from the last two years, or detail significant changes to living situation/funding/support/function

Browse File

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Step 3/6

NDIS Details and Consent

Please note: Therapists can only provide treatment with a valid Service Agreement – this means the Service Agreement has been signed and returned, and it is before the Agreement End Date.
To ensure you don't miss out on any planned treatments, please ensure we are notified if a new plan has been put in place, or an existing plan is extended.

NDIS Plan Number:

NDIS Plan Dates:

Participant Signs Consent?

Responsible Person Name

Phone

Relationship

What are the NDIS goals for this plan?

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Step 4/6

Services and Appointment Scheduling

Adjustability charges the standard SA NDIS rate for Area MMM1-5:
Occupational Therapy service @ $193.99 per hour Physiotherapy service @ $183.99 per hour
Travel labour time costs incurred to and from appointments will be charged at 50% of the applicable therapy rate, up to a maximum of 30-minutes each way within MMM1-3 (major metropolitan areas), and 60-minutes each way within MMM4-5 (rural and remote areas) PLUS Travel mileage will be charged at $0.98 per kilometer divided between all participants on the trip.

How is the plan funding managed?

NDIA Plan Manager Self-managed

If by a Plan Manager or Self Managed, who is responsible for the account?

Name

Phone

What is the budget that may be included on our service agreement for funding allocation?*

Is this from their Capacity Building Supports - Improved Daily Living (CB Daily Activity) budget?

Appointments – best person to contact for appointment scheduling:

Name

Phone

Relationship

What service is required?

Occupational Therapy Physiotherapy

Do you require a report?

If Yes, what type of report?

Plan Review Assistive Tech Housing

Preferred timeframe for report completion

Who will be present for the initial appointment (besides the Participant)?:

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Step 5/6

Referrer Details

Referrer Name

Job Title / Role

Referral Date

Name of Organisation (If applicable)

Phone

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Step 6/6

Safety

Do you/the Participant agree to follow government control guidelines relating to COVID-19 (such as mask-wearing, socially distancing, etc..?)

Is anyone at your / the client's property, known to be aggressive or violent? If YES, please describe

Does anyone at your/the clients property have a criminal history? If YES, please describe

Does the client have a behavioural support plan in place? If YES, please describe

Is there a history of people using drugs or alcohol at the property? If YES, please describe

Are you aware of any firearms being stored at the property? If YES, please describe

Are you aware of any occupant having an infectious disease? (i.e. chicken pox / shingles / gastro, COVID19 etc.) If YES, please describe

Do you have any pets at your premises? If YES, please describe

Are there any other factors we should be aware of? If YES, please describe

✓

Referral Submitted!

Thank you. Your referral has been successfully submitted.
Our team will be in touch with you shortly.

NDIS Referral Form

Occupational Therapy & Physiotherapy

Participant Details

Diagnosis and History

NDIS Details and Consent

Services and Appointment Scheduling

Referrer Details

Safety

Referral Submitted!

Participant Details

Diagnosis and History

NDIS Details and Consent

Services and Appointment Scheduling

Referrer Details

Safety

Referral Submitted!