Referral Form

Referral Details

Date of Referral *

Referrer Name *

Relationship to Client *

Organisation (if applicable)

Contact Phone *

Contact Email *

Client's Details

Full Name *

Date of Birth *

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/Carer Details (if different from referral details)

Parent/Carer Full Name

Parent/Carer Contact Phone

Parent/Carer Contact Email

What's your relationship to the client? (e.g. mother, father, step-parent, foster carer, guardian)

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, Mental Health Care Plan)Private (out-of-pocket payment)Private Health InsuranceUnsure/Would like to discuss further

NDIS Participant Number

NDIS Plan Manager Name

NDIS Plan Start Date

NDIS Plan End Date

NDIS Funding Management

Plan-managedSelf-managedAgency managed (Not accepted - see note below)

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

Type of Referral

What service/s are you referring for? *

Occupational TherapyClinical CounsellingSupport Work or MentoringUnsure/Seeking advice

What service or assessment are you requesting? *

Ongoing therapy interventionFunctional Capacity Assessment and ReportSensory Profile Assessment and ReportSupported Independent Living (SIL) Assessment and ReportAssistive Technology Assessment and ReportOngoing support work/mentor sessionsHydrotherapy/Aquatic therapyUnsure / Seeking advice

What are the key intervention areas you would like us to focus on? *

Additional information to help us understand this referral

Safety & Risk Information

We ask that you complete this section honestly and thoroughly to ensure safe service delivery. Please note, our team will ask for more information in our pre-initial phone call. If there is immediate risk to the client or others, please call 000.

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

YesNo

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

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PBS Practitioner Name

PBS Practitioner Company Name

PBS Practitioner Email

If you ticked any of the above, please provide details.Include: when it last occurred, typical triggers, early warning signs, effective strategies/de-escalation, any known hazards, and level of supervision required.

Medical/Safety Plans (Optional)

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

Legal/Custody Considerations (Optional)

YesNo

If you ticked yes, please provide details

Current Supports

Please list any other health professionals, support workers, or services currently involved. Knowing who is already on the team helps us coordinate care, avoid duplication, and work together to support the participant’s goals. Please note, we will not contact these services until a Consent to Exchange Information form has been completed.

Please list the names, roles, and organisations of current supports (if known).For example: GP – Dr Smith (Green Clinic); Speech Pathologist – Jane Brown (SpeakUp Therapy); Support Coordinator – John White (Better Supports).

Scheduling & Location

We will do our best to meet your preferences, however we cannot guarantee specific days, times, or locations. Our team will contact you to confirm availability.

Preferred days/times for sessions *

Where would you prefer sessions to take place? *Please note: Our Mawson Lakes clinic space is a single therapy room, most suitable for counselling clients. Access involves two flights of stairs, so this location may not be suitable for all participants. Home, school, or community visits may be more appropriate depending on needs.

Supporting Documentation

Attach documents here (e.g. NDIS plan, Medicare plan, reports, behaviour or seizure plans)

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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).

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

Yes No

Consent Statement

By submitting this referral, I confirm that I have consent from the client (or their parent/guardian if under 18) to share this information with Roles & Goals Therapy Services. I understand this information will be stored securely and used only for the purpose of providing services

Do you agree to the above consent statement? Please choose one: *

Yes No

Signature & Date

Name *

Signature *

Clear

Date *