Referrer Details

Date of Referral *

Referrer Name *

Relationship to Client *

Organisation (if relevant)

Phone Number *

Contact Email *

Client Details

First Name *

Last Name *

Date of Birth (DOB) *

Pronouns (e.g. she/her, he/him, they/them)

Home Address *

Street address *

City *

State *

Postcode *

Primary diagnosis (If none, write N/A) *

Language spoken at home, if not English

Parent/Caregiver Details

Parent/Carer Full Name

Parent/Carer Phone

Parent/Carer Email

What's your relationship to the client?

Funding Details

I understand that a client cannot be placed on the Roles & Goals Therapy Services waitlist until all required funding details have been provided (for NDIS clients this includes NDIS number, plan dates, and plan manager/invoice contact). If services are funded through Medicare, Private Health, or out-of-pocket payment, I acknowledge that relevant billing details may still be requested before services commence. *

Yes – I understand, and will be sure to fill in the prompts belowNo – Please note that Roles & Goals Therapy Services will be unable to fulfil the referral until this information is received

How will therapy services be funded? *

NDIS FundingMedicare (e.g., Chronic Disease Management/ EPC plan)Private (out-of-pocket payment)Private Health InsuranceUnsure/Would like to discuss further

NDIS Participant Number *

NDIS Plan start *

NDIS Plan End *

NDIS Funding Management *

Agency-managedPlan-managedSelf-managed

Please note that Roles & Goals Therapy Services is currently an unregistered NDIS provider and cannot accept Agency-managed clients.

NDIS Plan Manager Name *

Type of Service

What service/s are you referring for? *

Occupational TherapyClinical Counselling or CounsellingAllied Health AssistantUnsure/Seeking advice

What service or assessment are you requesting? *

Ongoing therapyFunctional Capacity Assessment (FCA) and ReportSensory Profile Assessment and ReportSupported Independent Living (SIL) Assessment and ReportAssistive Technology Assessment and ReportUnsure - I would like advice

Is there anything else you would like us to know?Please describe the main reason for referral, any current concerns and what you hope to achieve through our services.

Safety & Risk Information

Please share any information that may help us provide safe and appropriate support. Our team will discuss relevant details with you during the phone call before your first appointment. If anyone is in immediate danger, call 000.

Is there a Positive Behaviour Support (PBS) plan in place? *

YesNoUnsure

Please provide a copy of the PBS plan, if applicable.

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Please tell us about any concerns selected above. *Include: when it last occurred, typical triggers, early warning signs, effective strategies/de-escalation, any known hazards, and level of supervision required.

Is there any personal history or experience we should consider to help the person feel safe during services? *Please share only what is relevant and comfortable to disclose. Detailed accounts of traumatic experiences are not required.

Medical/Safety Plans (Optional)

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Upload any relevant plans (e.g., Seizure Management Plan, Allergy/Anaphylaxis Plan, Safety Plan)

Are there any legal, guardianship, parenting or court arrangements that affect consent, contact, information sharing or attendance? *

YesNoUnsure

If yes or unsure, please explain the relevant arrangements. *Include who can provide consent and any restrictions on contact or information sharing. Our team may request relevant documents.

Current Support Team

Please tell us about any health professionals, support workers or services currently involved. This helps us understand the person’s support team and coordinate care where appropriate.

We will only contact these providers once a Consent to Exchange Information form has been completed.

Who is currently involved in the person’s care or support? *Please include their name, role and organisation, if known. Examples include a GP, speech pathologist, psychologist, support coordinator, support worker or another therapist. If there are no current supports, or you are unsure, please write “None” or “Unsure”.

Scheduling & Location Requests

We will do our best to accommodate your preferred days, times and locations. Availability depends on clinician schedules, travel requirements and suitability for the service requested. Our team will discuss available options with you.

Off-site appointments: Travel charges apply to home, school and community visits. Our team will explain these charges before appointments are arranged.

School appointments: Some schools charge providers a fee to attend. Our team considers these arrangements individually, and school visits are offered at our discretion. Any arrangements affecting your service will be discussed with you beforehand. School access fees are not currently passed on to clients.

What days and times are you available for sessions? *We will do our best to accommodate your preferred days, times and locations. Availability depends on clinician schedules, travel requirements and suitability for the service requested. Our team will discuss available options with you.

Supporting Documents

Please attach any relevant documents - optional

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For example, assessment reports, referral letters, relevant sections of an NDIS plan, or a Medicare referral or treatment plan. You do not need to upload documents already provided elsewhere in this form. If documents are unavailable, our team can discuss these with you.

Privacy Policy

We respect your privacy and keep your information safe. Your details are only used to provide therapy services and support, and will never be shared without your consent (unless required by law).

Our Privacy Policy is available on the Roles & Goals Therapy Services website.

Do you accept the Privacy Policy (available on our website)? *

Yes No

Referral Consent

By submitting this referral, I confirm that:

The information provided is accurate to the best of my knowledge.
I am referring myself, am authorised to consent on the person’s behalf, or have obtained consent from the person or their authorised representative to submit this referral.
I understand that Roles & Goals Therapy Services will use this information to review the referral and contact the relevant people about services.
I understand that submitting a referral does not guarantee an appointment or immediate availability.

Permission to contact other providers will be sought separately through a Consent to Exchange Information form.

I confirm the above statements. *

Yes No

Signature & Date

Name *

Signature *

Clear

Date *