NDIS Referrals

Thank you for choosing Smart Solutions Rehab Group to support you in reaching your goals. To make an NDIS 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.

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Referral Date*

DD dash MM dash YYYY

Depending on your location and required therapy, we may be able to process your referral faster if you are happy to receive services via TeleHealth. Please select the TeleHealth option as well as the required services if this is suitable.

Services required (select all that apply)

Occupational Therapy

Physiotherapy

Exercise Physiology

Speech Pathology

Podiatry

Dietetics

Social Work

Allied Health Assistance

Region where services are required

Sunshine Coast

Moreton Bay

North Brisbane

Gympie area

Fraser Coast

Hervey Bay area

Are you submitting this referral for yourself?*

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Section Break

Referrer details

Referrer name*

First Name Last name

Agency or organisation*

Phone*

Email*

Enter Email Confirm Email

Relationship to client

Please describe

Client/participant details

Client/participant name*

First name Last name

Date of birth*

DD slash MM slash YYYY

Gender*

Address*

Street Address Address Line 2 City State Post Code

Postal address

Uncheck if different from above

Address/PO Box Address Line 2 City State Post Code

Home phone*

Mobile*

Email*

Enter Email Confirm Email

Preferred contact method*

Does the person being referred identify as Aboriginal or Torres Strait Islander?*

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Prefer not to say

Does the person being referred have any religious or cultural considerations we should be aware of?*

Yes (Please provide details below)

Please provide details

Does the person being referred require the assistance of an interpreter in order to access services?*

Yes (Please provide details below)

Please provide details

Reason for referral:*

Diagnosis group (tick all that apply)*

* We will ask for further information in the risk screening section

Physical

Sensory *

Cognitive *

Psychosocial *

Primary diagnosis*

Amputation

Autism

Brain injury

Cerebral Palsy

Deaf

Blind

Genetic condition

Hearing impairment

Mental health (please specify below)

Neurological

Spinal injury

Stroke

Vision impairment

Other (please specify below)

Secondary diagnosis (if applicable)

Amputation

Autism

Brain injury

Cerebral Palsy

Deaf

Blind

Genetic condition

Hearing impairment

Mental health (please specify below)

Neurological

Spinal injury

Stroke

Vision impairment

Other (please specify below)

Please provide further details

Please provide any further details of person's disability or other relevant health conditions

NDIS information

Does the person being referred already have an NDIS plan in place?*

Yes (please provide details below)

Plan details

NDIS plan number*

How is the plan managed?*

Self managed

Plan managed

Agency (NDIA) managed *

Plan start date*

DD slash MM slash YYYY

Plan end date*

DD slash MM slash YYYY

* Please note – as an agency-managed participant you are giving consent for Smart Solutions Rehab Group to claim payment for services provided through the Myplace Provider Portal. If you service agreement is not signed and returned prior to services commencing, Smart Solutions Rehab Group will not claim for any future services provided.

Billing contact

Name

Invoicing email

Where would you like us to send invoices?

Enter Email Confirm Email

Would you like to provide us with a copy of the NDIS plan?

Yes

Please upload the plan here

Max. file size: 100 MB.

If no, please provide us with the NDIS plan goals so our clinician/s can plan accordingly.

No NDIS plan in place

Please continue to the next page to arrange for a client services coordinator to call and discuss your requirements.

Referral phone call

The SSRG Team will be in contact to confirm acceptance of your referral or request more information.

Who should SSRG contact to discuss this referral and arrange/confirm appointments?

Please contact person being referred

Please contact the referrer

Other (Please provide details below)

Name*

First Name Last name

Relationship

Support Coordinator

Support Worker

Legal guardian

Next of kin

Other support person

Other

Phone*

Is the client Under Office of Public Guardian*

Yes

Does the client have a support coordinator*

Yes

Best day/s to call (please tick all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Best time/s to call (please tick all that apply)

8:30am – 10:30am

10:30am – 12:30pm

12:30pm – 2:30pm

2:30pm – 4:00pm

Environmental risk screening

Does the client consent to a home visit?

Are all occupiers agreeable to a home visit?

Please provide names of anyone who will be present during the visit

Please note that for our clinician's safety during your consultation we require that the premises be smoke free throughout the appointment, that all pets are restrained, and that visitors are kept to a minimum.*

Please tick this box to confirm you can meet these safety requirements during your appointment.

Please provide details of anything else the clinician needs to know before accessing the premises

For example information about parking or access to the property

Have there been any recent acts of abuse, aggression or violence on the premises?

Yes

Please provide details

Does anyone residing at the premises receive services from agencies such as Mental Health, Alcohol and Other Drugs?

Yes

Please provide details

Does anyone residing at the premises have any medical or psychiatric conditions of which our clinician should be aware?

Yes

Please provide details

Does anyone residing at the premises have a forensic history, a current criminal record, conviction, or supervision order?

Yes

Please provide details

Are there people who should NOT attend the premises while your clinician is present?

Yes

Please provide details

Does anyone residing at the premises have a current contagious condition (e.g., HIV, Hepatitis, Staph)?

Yes

Please provide details

Is anyone residing at the premises currently taking cytotoxic medications? (usually prescribed for cancer)

Yes

Please provide details

Comprehensive risk screening

Due to the diagnosis group selected, we will need to gather some additional information to better understand your circumstances. Once we receive this referral form, someone from our team will contact you during the time period you previously identified.

Comprehensive risk screening

Due to the diagnosis group selected, we will need to gather some additional information about the participant to accurately assess the risk.

Symptoms

Please identify any symptoms below that are relevant to the participant (tick all that apply):

Excessive worry or fears

Unusual or illogical thoughts

Excessive anger or irritability

Paranoia

Unpredictable behaviours

Auditory hallucinations (hearing voices)

Visual hallucinations (seeing things)

Sensory sensitivities

Delusions

Aggressive/violent behaviour

Hoarding

Gambling

Thoughts of harm (self and others)

Suicidal ideation

Please provide further details

Please provide details of each symptom identified as well as duration and frequency of occurrence.

Challenging behaviours

Please identify any behaviours which are relevant to the participant

Hypersexuality

Inappropriate touching

Hiding

Refusal

Destruction of property

Impulsivity

Self-harm

Stealing

Hitting/biting/kicking

Difficulty with personal space

Screaming/swearing/yelling

Please provide further details

Please provide details of each behaviour as well as the duration and frequency of occurrence.

Current status of symptoms at current time:

Acute – current episode of increased symptoms

Chronic – symptoms well managed

Fluctuating – symptoms/presentation changing frequently

Please list any potential triggers the clinician should be aware of before engaging with the participant

Please provide details of any ways that the clinician can support a positive interaction with the participant

Service consent

The information below relates to the collection of the participant’s information during the provision of services. All information is collected by Smart Solutions Rehab Group in accordance with our privacy policy which is available on request, or can be accessed via our website at ssrg.com.au/resources/privacy-policy/

Please read the following information carefully*

Smart Solutions Rehab Group (the Provider) needs to collect information about you (the Client/Participant) for the primary purpose of quality service provision. To thoroughly assess, diagnose, and provide therapy we need to collect some personal information about you.

The information will be used for:
a) The administrative purpose of running the company
b) Billing purposes – either directly or through an insurer or compensation agency
c) Use within the company for collaboration among multiple practitioners in the interest of maximising service delivery
d) Disclosure of information to your doctor/s, other health practitioner/s, or to professional trades people (e.g. for a home modification) to ensure best possible care for you (you can specify exactly who SSRG is authorised to request information from or release information to below)

By providing consent you are agreeing to receive services from Smart Solutions Rehab Group and (where applicable) confirming that you are authorised to provide that consent on behalf of the participant named in the section ‘client/participant details’.

I have read the above information and consent to receiving allied health services from Smart Solutions Rehab Group (and, if applicable, I confirm that I am authorised to provide consent on behalf of the participant) .

Consent for sharing information

The information below relates to other health professionals or relevant stakeholders with whom we may need to share information in the provision of care. Please read through the information carefully and confirm who SSRG is able to request information from or release information to.

I consent to SSRG requesting information relevant to my care from the following service providers:

Please tick all that apply and provide further details below where needed

Department of Communities, Child Safety and Disability Services

Medical practitioners (e.g., GP, Paediatrician, Psychiatrist)

Queensland Health

Relevant non-government support services

Family members

Authorised representatives

Other

Please provide details

You do not have to provide this information right now, however we may request it at a later date. You can provide up to 8 names by clicking on the +

Name

Relationship

Contact information

I consent to SSRG releasing relevant information to the following service providers:

Please tick all that apply and provide further details below where needed

Department of Communities, Child Safety and Disability Services

Medical practitioners (e.g., GP, Paediatrician, Psychiatrist)

Queensland Health

Relevant non-government support services

Family members

Authorised representatives

Other

Please provide details

You do not have to provide this information right now, however we may request it at a later date. You can provide up to 8 names.

Name

Relationship

Contact information

Other consent

Do you consent to SSRG liaising with and disseminating relevant information to your current support co-ordinator or any future support coordinator?*

Yes

I don’t have a support coordinator

Do you consent to your SSRG clinician/s taking photographs of you or your home environment for the purposes of treatment, evaluation or training purposes?*

Yes

Name of person providing consent

First Last

Marketing information

How did you hear about Smart Solutions Rehab Group?*

Google

SSRG website

Social media

Friend/family

Advertising material

Care provider/GP

Support coordinator/case manager

Other

Date

MM slash DD slash YYYY

Supporting Documents

Please upload any additional supporting documents, reports, Positive Behaviour Support Plans here.

File

Drop files here or

Max. file size: 100 MB, Max. files: 20.

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