Who is providing information for this referral? *

How did you hear about Access Therapist? *

MyCareSpace reference ID number

Karista Reference Form

1). PARTICIPANT DETAILS

First Name *

Last Name *

Date of Birth *

Address *

Suburb *

Postcode *

Living Arrangements

Phone *

Email Address *

Gender Assigned at Birth *

MaleFemalePrefer not to answer

Preferred Pronouns: *

Cultural Preference

Are you Aboriginal or Torres Strait Islander

YesNoPrefer not to answer

Do you require an Interpreter?

YesNo

Preferred Language

Primary Diagnosis *As specifically listed on NDIS Plan/Diagnostic Letters i.e. Autism Level 2, Schizophrenia

NDIS Listed Goals *

What are you seeking from this referral?

About me:Please provide an additional information that may be of benefit to your therapist

2). KEY CONTACTS

Key Contact Name

Key Contact Phone

Key Contact Email

Preferred method of contact? *

PhoneEmailSMS

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

3). SERVICE DELIVERY PREFERENCES

*Currently servicing Metro Melbourne, Gold Coast, and Newcastle*

Preferred Delivery Mode *

In HomeTelehealthIn SchoolBoth In Home/School and 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 (Please note: we cannot supply services to Agency Managed Participants) *

Plan ManagedSelf Managed

Upload NDIS Plan

Browse

Upload Reports/Assessments

Browse

Plan Manager *

Plan Manager Email *

5). Assessment/Therapy Services Required

Initial Assessment

Functional Capacity - 8-14 hours dependent on number of meetings required, travel and complexitySensory Profile – 6-10 hours dependent on sensory programme desiredEquipment/Assistive Technology – 8-12 + hours dependent on number of meetings and travel required – could be greater than 12 if more than 1 piece of equipment or supplier is required or if significant time and research is required due to the technology being complex

Ongoing Therapy Sessions - 6 Hours minimum

Sessions Only - each session taking 1-2 hours dependent on travel. Please note additional time is required for preparation, resource building and liaison when delivering sessions to ensure they have the most effective outcome. The NDIS also expect that at the conclusion of a therapy program a summary report is provided. For this reason cost of therapy sessions services should be estimated by multiplying the number of sessions you desire by 2 and adding 8 hours to cover the preparation, resource building, liaison and report. e.g. Number of sessions x 2 + 8 = estimated funding hours required.

Complex Assessment - between 14-20 Hours (depending on complexity)

Home ModificationsSupported Independent LivingSpecialist Disability Accommodation

Pre-Planning Assessment - 5 hours (estimated)

Assessment

Services - Quote Estimator

Access Therapist charges the standard NDIS rate of $193.99 per hour for services, $97 per hour for travel costs and $0.99 per kilometre travelled as per the 2025-2026 NDIS Price Guide.

How many hours are you requesting for services (including travel and reporting)?

Variable Hours

Variable Price per hour

Variable Total Hours Required

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 #

Access Therapist charges the standard NDIS rates per hour for travel in areas MMM1 – 5 price guide 2025 - 2026

Do you also require Telehealth for other services? (Psychology, Speech Pathology, Dietetics etc)

YesNo

Other Services Required

PsychologySpeech PathologyDietetics

Other services Notes/Requirements:

Vaccination Status (Covid):

Access Therapist endeavors to eliminate or minimize the risks of COVID-19 as far as reasonably practicable. Access Therapist identifies that under Workplace Health and Safety (WHS) guidelines, the COVID-19 vaccine is not a reasonably practicable control measure to manage the risks of COVID-19 in the workplace. Our risk assessment meets the Access Therapist WHS duties by applying other controls to address the risk of COVID-19.

Reference: https://covid19.swa.gov.au/covid-19-information-workplaces/industry-information/general-industry-information/vaccination

Access Therapist employs both Covid vaccinated and unvaccinated Therapists *

I would like to proceedNo, I would not like to proceed

Comments

6). CONSENT

Signature *

Draw signature|Type signatureClear

Date *

I consent that 3 hours of Funding will be released to Access Therapist for the first 3 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

*

Authorised Representative for Access Therapist

I have discussed the Service Agreement with the Participant or authorised representative, and I am satisfied that they understand the proposed uses and disclosures and have provided their informed consent to these.
(Verbal consent should only be used where it is not practicable to obtain written consent)

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
Occupational Therapy	Initial Consult(Including Travel, initial consult, review of referral, liaison and preparation. )	$193.99	3	$581.97
Please allow for	Travel, Kilometers, Report Writing, Liaison and Communication, Research etc		Total Budget	$581.97

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 charges the standard NDIS rates per hour for travel in areas MMM1 – 5 price guide 2025 - 2026

Other 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
Psychology	Initial Consult (Including initial consult, review of referral, liaison and preparation. )	$232.99	2	$465.98
Please allow for	Report Writing, Liaison and Communication, Research etc		Total Budget	$465.98

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

What Are Our Fees

Access Therapist will invoice for services in accordance with the NDIS Price Guide 2025-2026. We monitor any changes to the NDIS Price Guide and will make any changes when required.

Provider Travel is billed in accordance with the NDIS Price Guide 2025 -2026 and follows the Modified Monash Model. This model categorises all Australian locations as urban, regional, or remote. We will assist participants to minimise the travel costs where possible.

Ranging from MMM1 (city) – MMM7 (very remote)

(where the therapist’s journey is the last appointment of the day, they can claim a return trip fee)

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 theNational 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 AccessTherapist’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

Thank you for the referral

Ph:1300 102 792 ndis@accesstherapist.com.au

Occupational Therapy/ Speech Pathology/ Psychology/Dietitics

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

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