Therapy Pro Referral Form for Therapy Services

We strive to meet the needs of our clients by offering quality services by qualified and well supported therapists.

In order to proceed through this form quickly please have the relevant paperwork and details handy (this may include Medicare details, NDIS details, referral details, etc.). The more information you can share with us now, the quicker we can connect you with your therapist.

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Yes, I would like to make an online referral for a person to Therapy Pro

(clients aged 13+ years) Make an online referral for Therapy Pro for Kids (clients aged 0-12 years)

About the person being referred

Are you submitting this referral for yourself?(Required)

Please tick the therapy type/s you are looking for(Required)

Psychosocial Assessment and/or Support

Occupational Therapy

Positive Behaviour Support (PBSP)

Psychology

Social Work

Speech & Language Pathology

Do you require a specific assessment or ongoing therapy?(Required)

To ensure uninterrupted care, Therapy Pro has increased the amount of telehealth sessions we can provide to new and existing clients. Please tick the service type you are looking for so we can process your referral faster(Required)

Face to Face Sessions

Telehealth Sessions

Either / Both

Where would the person like to receive our therapy services?

At home

School

Community

Daycare (early education child care)

Place of employment

Location Street Address(Required)

Location Suburb(Required)

Location Postcode(Required)

Location State(Required)

If there is a wait time for face-to-face services, would you consider telehealth to access your required services sooner?

Yes

Telehealth services consent

The person/client is able to and consents to receiving telehealth therapy services

Client Name(Required)

Client Surname(Required)

Client Street Address(Required)

Client Suburb(Required)

Client Postcode(Required)

Client State(Required)

Client’s Mobile Phone Number(Required)

Client’s Other Phone Number

Client Email(Required)

Which gender do you/does the client identify as(Required)

Date of birth(Required)

DD slash MM slash YYYY

Reason for Referral

Does the person being referred have a diagnosis or disability?(Required)

Are there any other complex or chronic medical conditions we should be aware of?(Required)

Are there any requirements we should be aware of, for example: male or female therapist, specific days/time for appointments, or identify any behaviours of concern (if applicable) that may impact allocating a therapist?

Are there any risks we should be aware of that may impact allocating a therapist?(Required)

Please provide supporting risk documentation or positive behaviour support plan (if available)

Max. file size: 256 MB.

Would the person like to share any cultural information that Therapy Pro should understand or be aware of?

Does the person being referred identify as

Does the person being referred require an interpreter? (if yes, provide language spoken)

Most preferred contact method(Required)

Phone

SMS

So we can collect the required information, please select which kind of referral this relates to.

What is the funding type for this referral?(Required)

Please give details(Required)

WorkCover claim number(Required)

Work capacity certificate

Max. file size: 256 MB.

Referral reason(Required)

Medicare information(Required)

Medicare Number(Required)

IRN Number on Medicare Card (1, 2, 3 etc)(Required)

Date(Required)

DD slash MM slash YYYY

Does the person has a referral letter from their medical provider?

Yes

You can attach the referral letter here. NOTE: Referral letter must be received before therapy can commence

Max. file size: 20 MB.

NDIS Participant Number(Required)

Plan Start Date

DD slash MM slash YYYY

Plan End Date

DD slash MM slash YYYY

Are there funding periods in your NDIS plan?(Required)

Yes

How are the funding periods split for therapy?(Required)

Monthly

Quarterly

Half yearly

Is your funding amount split evenly across your funding periods?(Required)

Yes

What is the allocated amount for each funding period?(Required)

Where will the therapy funds be drawn from?(Required)

Independent Daily Living

Behaviour Support / Improved Relationships

Other / Unsure

Please describe your funding breakdown including start date, end date, and allocated amount for each funding period(Required)

Please include any of the following: a copy of the NDIS plan, a copy of plan goals, or a snippet of participants goals and/or budget. If you are unsure about something or would like to chat with someone about this referral, please call 1300 004 414 and our customer service team will be happy to support you.(Required)

Max. file size: 256 MB.

Select how your plan is managed (Plan Management Type)(Required)

If you are plan managed, please enter the Plan Management person's name or the company name.(Required)

If you are agency managed, is your plan under the new NDIS Computer System - PACE?

Yes

Is the person currently receiving any allied health services? Please describe

Are there any additional documents you would like to share? E.g. previous assessments, medical or legal information

Max. file size: 256 MB.

About the person's decision maker, and the referrer completing this form

Who is the decision maker / plan nominee / guardian?

Decision Maker Name

Decision Maker Surname

Decision Maker Phone

Decision Maker Email

Decision Maker Relationship to Client

Who is the best contact for scheduling of appointment?(Required)

Client / Self

Decision maker

Referrer Name(Required)

Referrer Surname(Required)

Referrer Phone(Required)

Referrer Email(Required)

Case Manager Name(Required)

Case Manager Surname(Required)

Case Manager Phone(Required)

Case Manager Email(Required)

Referrer Agency or Organisation

Referrer Role or Relationship to Client

Does this person has a support coordinator?

Yes

Support Coordinator Name(Required)

Support Coordinator Surname(Required)

Support Coordinator Phone(Required)

Support Coordinator Email(Required)

Support Coordination Agency or Organisation

Do you have consent from the person that you are referring (or their representative) to share the information in this form?(Required)

Yes

Do you consent to your information being shared with our sister organisation (Adaptability Therapy in QLD and Tashacare in VIC) who may contact you if they have a more immediate availability for the services you are enquiring about?

Yes

How did you hear about Therapy Pro?(Required)

Comments

This field is for validation purposes and should be left unchanged.

Notes and Instructions

When you have completed and submitted the form correctly, you will receive a notification email. If you do not receive a notification email (check your junk emails) then we do not have a copy of your referral.

When you click on submit you will receive this message at the top of the page: ‘Thank you very much for your referral. Someone from our intake team will be in contact with you shortly.’

If you click on submit and do not receive the thank you message, the form has not been submitted. You will need to scroll to the top of the form to see what the error message is saying.

Any fields where information is required that hasn’t been included when you hit SUBMIT, will display with a red box around them. Please complete these red fields and hit submit again.

Therapy Pro Referral Form for Therapy Services

About the person being referred

Notes and Instructions

Learn More

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