Aged Care Referrals

Make a referral

Thank you for choosing Smart Solutions Rehab Group to support you in reaching your goals. To make an Age Care referral simply complete the online referral form below. Once we receive your referral, a Service Coordinator will contact you as soon as possible.

Please note we are an adult (16+) service provider, and are not currently accepting paediatric referrals.

If your referral is for mental health services please contact our client services team on 1300 729 190 before completing the referral form.

"*" indicates required fields

Referral Date

DD dash MM dash YYYY

Referrer details

Referrer name*

First name Last name

Agency or organisation*

Phone*

Email*

Enter Email Confirm Email

Relationship to client*

Client/participant details

Client/participant name*

First name Last name

Date of birth*

DD slash MM slash YYYY

Gender*

Client Address*

Suburb*

State*

Home phone

Mobile*

Email*

Preferred contact method

GP Details

GP Name

GP Practice

GP Contact Information

Client Information

Client Information Provided

Health Summary

Care Plan

Discharge Summary

Funding Details

HCP

CDC

Self-Funded

STRC

CHSP

HSS

Insurer

DVA Gold

DVA White

HCP Package level

☐ CDC – Medicare No

Self-Funded

STRC – Agency

CHSP – Agency

HSS – Type

Insurer – Agency

DVA White Card Condition

Billing Information

Billing Agency

Billing Contact Name

Billing Email Address

Urgency

High

Moderate

Low

Feedback Required

Yes

Location

Telehealth

Clinic

Home Visit

Medical Details

Diagnosis / PMHX

Please select your medical details:

Please select at least 1.

Physiotherapy

Physiology Location

Home Visit

Telehealth

Clinic

Physiotherapy Options

Soft Tissue Treatment

Simple Equipment (Single sticks, Crutches, 4ww, Rollators)

Transfer plan

Mobility training

Pain Management

Hydrotherapy

Manual Handling Training

Home Exercise Program

Physiotherapy Request details

Exercise Physiology

Exercise Physiology Location

Home Visit

Telehealth

Clinic

Exercise Physiotherapy Options

Exercise program

Gym based activities

Hydrotherapy

Simple Equipment

Transfer plan

Exercise Physiotherapy Request details

Occupational Therapy

Occupational Therapy Location

Home Visit

Telehealth

Clinic

Occupational Therapy Options

Pressure Care

Simple Modifications (Rails Ramps, Wedges, HHSH, Chair raisers)

Complex Modifications (Bathroom remodelling, Kitchen remodelling, Laundry remodelling, Complex ramps)

ADL Skills Re-Training

Cognitive Assessment

Simple Equipment (Manual wheelchairs)

Complex Equipment (Scooter, Recliner Chair, Complex Wheelchair, Power drive wheelchair, Bed and pressure redistribution mattress)

Therapy

Transfer Plan

Occupational Therapy Request details

Speech Pathology

Speech Pathology Location

Home Visit

Telehealth

Clinic

Speech Pathology Options

Initial Ax

Swallow Ax

Mealtime Management Program

Communication

Social Skills

Augmented Communication Technology

Therapy

Speech Pathology Request details

Social Work

Social Work Location

Home Visit

Telehealth

Clinic

Social Work Options

Initial Ax

EPO advice

Family dynamics

Financial Affairs

Applications

Other

Grief and Loss

Social Work Request details

Dietetics

Dietetics Location

Home Visit

Telehealth

Clinic

Dietetics Options

Initial Ax

Meal Planning

Weight loss

Weight gain

Other

Dietetics Request details

Podiatry

Clinic Appointments ONLY

Podiatry Options

Initial Ax

Nail care

Shoes

Condition Treatment

Orthotics

Other

Podiatry Request details

SSRG Home Visit Safety Policy is as follows:

All pets must be restrained during visits.
Homes must be smoke free during staff visits.
Aggression, abuse, and harassment are not tolerated.
All safety issues identified must be addressed or mitigated prior to staff attendance.
Visitors are to be restricted during visits.
Staff must have access to emergency use of telephones.
Access doors need to remain unlocked during visits.

For this referral to be accepted, the Risk Assessment below needs to be completed for either the Home Visit or In Clinic appointment.

For Home Visit Appointments

Consent*

Pre-Visit: Does the client consent to the home visit?

Yes

Comments/ Actions Taken

Social*

Pre-Visit: Does anyone else reside in the home or will anyone else be present during home visits?

Yes

Comments/ Actions Taken

Personal Safety*

Pre-Visit: Is there a risk to our staff member’s personal safety?

Unrestrained pets
History or risk of aggression, abuse or violence from client or anyone else in the home?
Drug or alcohol use
Mental Health conditions
Behavioural support plans
Criminal History
Contagious conditions (e.g., HIV, staph, Hepatitis)
Cytotoxic medication use
Weapons

Yes

Comments/ Actions Taken

Access*

Pre-Visit: Is external and internal access to the property safe?

Isolation
Unsealed roads
Phone coverage/home phone access
Parking
Key Safe (code)
Slip or trip hazards
Overgrown foliage
Clutter/hording/squalor
Vermin
Smoking

Yes

Comments/ Actions Taken

For Clinic Appointments Only

Personal Safety

Is there any client risk of :

History or risk of aggression, abuse, or violence
Drug or alcohol use
Mental Health conditions
Medical Conditions
Behavioural support plans
Criminal History
Contagious conditions (e.g., HIV, staph, Hepatitis)
Cytotoxic medication use

Yes

Comments/ Actions Taken

Name

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