TELEHEALTH REFERRAL FORM

Who is providing information for this referral? *

How did you hear about Access Therapist? *

Karista Reference Number

MyCareSpace Reference Number

Preferred method of contact: *

PhoneEmailSMS

1). PARTICIPANT DETAILS

First Name *

Last Name *

Date of Birth *

Phone *

Email Address *

Address *

Suburb *

Postcode *

Living Arrangements

Gender *

MaleFemaleOtherPrefer not to answer

Cultural Preference

Are you Aboriginal or Torres Straight Islander

YesNoPrefer not to answer

Do you require an Interpreter?

YesNo

Preferred Language

Primary Diagnosis *

NDIS Listed Goals *

What are you seeking from this referral?

About MePlease add any information that may be of benefit for your therapist

2). KEY CONTACTS

Key Contact Name

Key Contact Phone

Key Contact Email

Emergency Contact must be different from Key Contact

Emergency Contact (if applicable)

Emergency Contact Phone

Emergency Contact Email

Who is your Emergency Contact?

Parent/GuardianSupport CoordinatorAdvocateOther

Support Coordinator

YesNo

S.C. Organisation

S.C. Name

S.C. Phone

S.C. Email

Local Area Coordinator

YesNo

LAC Organisation

LAC Name

LAC Phone

LAC Email

General Practitioner

YesNo

GP Organisation

GP Name

GP Phone

GP Email

3). SERVICE DELIVERY PREFERENCES

Preferred Delivery Mode *

Telehealth

Do you have a preferred therapist?

YesNo

Name of therapist

Video Link Delivered by

SMSEmail

Video Link Delivered to

ParticipantKey Contact

Preferred Time/s: *

9am -12pm12pm - 3pm3pm - 6pm

4). NDIS Plan Details

NDIS Number *

Plan Start Date *

Plan End Date *

How are Funds Managed *

Agency ManagedPlan ManagedSelf Managed

Upload NDIS Plan

Browse

Upload Reports

Browse

Plan Manager *

Plan Manager Email *

5). Assessment/Therapy Services Required

Service Required *

Occupational TherapySpeech PathologyPsychologyDietetics

(please select all services required)

Initial Assessment - 8-10 Hours minimum

Functional CapacitySensory ProfileEquipment/Assistive Technology

Ongoing Therapy Sessions - 6 Hours minimum

Sessions Only

Pre-Planning Assessment - 5 hours (estimated)

Assessment

Complex Assessment - 20 Hours (estimated)

Home ModificationsSupported Independent LivingSpecialist Disability Accommodation

Services - Quote Estimator

Access Therapist charges the standard NDIS rate of $193.99 per hour for services as per the 2024-2025 NDIS Price Guide.

How many hours are you requesting for services (including testing, reasearch, communications and reporting)?

Access Therapist charges the standard NDIS rate of $222.99 per hour for services as per the 2024-2025 NDIS Price Guide.

How many hours are you requesting for services (including testing, reasearch, communications and reporting)?

Occupational Therapy

OT Hours requested

OT Price per Hour

Total OT Budget

Psychology

(Total hours required)

Psychology Hours Required

Psychology Price per Hour

Total Psychology Budget

Speech Pathology

(Total hours required)

Speech Therapy Hours Required

Speech Therapy Price per Hour

Total Speech Budget

Dietetics

(Total hours required)

Dietetic Hours Required

Dietetics Price Per Hour

Total Dietetics Budget

Please specify the total budget required until the end of plan. # Please note - to make an allowance within the total budget for incidentals: e.g testing, research, communications, and report writing to meet NDIS standards #

6). CONSENT

Signature *

Draw signature|Type signatureClear

Date *

I consent that 2 hours of Funding will be released (per Service) to Access Therapist for the first 2 hours of service at time of referral, this enables us to book you in with the most appropriate therapist as soon as they become available. We will call you to provide an approximate time frame or an appointment time when we receive our referral.

*

I consent to share information for Access Therapist to assist me with the handling and linkage of services to and from the parties as listed in this referral form.I understand should the need arise and changes need to be made to my information I can change / withdrawal my consent at any given time, I will send my request in writing to ndis@accesstherapist.com.au

*

Schedule of supports

Access Therapist agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports	Service requirements e.g Assessment or Consults	Rate per hour	Units/hours	Total
Speech Pathology	Initial Consult (Including initial consult, review of referral, liaison and preparation. )	$193.99	2	$387.98
Please allow for	Report Writing, Liaison and Communication, Research etc		Total Budget	$387.98

Access Therapist agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports	Service requirements e.g Assessment or Consults	Rate per hour	Units/hours	Total
Occupational Therapy	Initial Consult (Including initial consult, review of referral, liaison and preparation. )	$193.99	2	$387.98
Please allow for	Report Writing, Liaison and Communication, Research etc		Total Budget	$387.98

Access Therapist agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports	Service requirements e.g Assessment or Consults	Rate per hour	Units/hours	Total
Psychology	Initial Consult (Including initial consult, review of referral, liaison and preparation. )	$222.99	2	$445.98
Please allow for	Report Writing, Liaison and Communication, Research etc		Total Budget	$445.98

Access Therapist agrees to provide the participant CAPACITY BUILDING SUPPORTS for Therapeutic Supports with the view of receiving:

Service Supports	Service requirements e.g Assessment or Consults	Rate per hour	Units/hours	Total
Dietetics	Initial Consult (Including initial consult, review of referral, liaison and preparation. )	$193.99	2	$387.98
Please allow for	Report Writing, Liaison and Communication, Research etc		Total Budget	$387.98

The supports and their prices are set out in the attached Schedule of Supports. All prices are GST inclusive (if applicable) and include the cost of providing the supports. Additional expenses (i.e. things that are not included as part of a Participant’s NDIS supports) are the responsibility of You, and are not included in the cost of the supports. Examples include entrance fees, event tickets, meals, etc.

Access Therapist Responsibilities

Access Therapist agrees to:

I. review the provision of supports at least annually with the participant;

II. once agreed, provide supports that meet the participant’s needs at the participant’s preferred times;

III. communicate openly and honestly in a timely manner;

IV. treat the participant with courtesy and respect;

V. consult the participant on decisions about how supports are provided;

VI. give the participant information about managing any complaints or disagreements, cancellation policy;

VII. listen to the participant’s feedback and resolve problems quickly;

VIII. give the participant the required notice if Access Therapist needs to end this Service Agreement (see ‘Ending this Service Agreement’ below for more information);

IX. protect the participant’s privacy and confidential information;

X. provide supports in a manner consistent with all relevant laws, including the National Disability Insurance Scheme Act 2013 (NDIS Act) and rules, and the Australian Consumer Law;

XI. keep accurate records on the supports provided to the participant; and

XII. issue regular invoices and statements of the supports delivered to the participant as per the NDIA’s Terms of Business for Registered Providers.

Responsibilities of You

You agree to:

I. inform Access Therapist about how they wish the supports to be delivered to meet the participant’s needs;

II. treat Access Therapist with courtesy and respect;

III. talk to Access Therapist if the participant has any concerns about the supports being provided;

IV. give Access Therapist minimum of 48 hours’ notice if the participant cannot make a scheduled appointment, noting that if the notice is not provided by then, Access Therapist cancellation policy will apply;

V. give Access Therapist the required notice if the participant needs to end this Service Agreement (see ‘Ending this Service Agreement’ below for more information); and

VI. let Access Therapist know immediately if the participant’s NDIS plan is suspended or replaced by a new NDIS plan, or the participant stops being a participant in the NDIS.

Payments - Access Therapist will seek payment for their provision of supports after You confirm satisfactory delivery.

Cancellation Policy

Out of consideration and respect for Access Therapist ’s time, You must provide Access Therapist with at least 48 hours’ notice of the cancellation of any supports. For cancellation of weekend supports, You must notify Access Therapist by 5:00pm on the previous Thursday. Failing to do so, will incur the full rate per hour. Please be aware that multiple cancellations or no shows will be recorded on the participants profiles – this information may be retrieved by NDIA. Where Access Therapist cancels a support due to operational reasons, the service will be rescheduled at no penalty to either party.

Thank you for taking the time to fill out and complete our referral form . Please do not hesitate to call

Next Steps

Once we have received our signed referral form, the intake team will allocate a suitable therapist to suit your needs and availability, we will then make contact to schedule an initial consult.

The method of receiving this communication is determined how you answer Service Delivery Preferences Box above.

Thank you for the referral

Ph: .................. ndis@accesstherapist.com.au

Occupational Therapy/ Speech Pathology/ Psychology/ Dietitian

Access Therapist Australia Pty Ltd Referral Form V1. Date created: 01.07.2025