Client Name *

First Name

Last Name

Main contact person *

First Name

Last Name

Relationship to client *

Indicate the preferred contact person for this referral

Client

Spouse/partner

Caregiver/NOK

Referrer

Alternative Phone Number

(###)

###

####

Services requested *

Choose from the following options

Package 1: Targeted Assessment + Report- $300 (excluding GST)

Package 2 - Standard Assessment + Report: $450 (excluding GST)

Package 3 - Equipment Trial/Evaluation + Report: $375 (excluding GST)

Package 4 - Major Home Modifications Assessment + Report: $900 (excluding GST)

Package 5 - Powered Mobility Assessment + Trials + Report: $1200 (excluding GST)

OT services - Hourly Rate $150 (excluding GST) for assessment, report & travel

Referrer Name

If this is a client referral, leave blank - otherwise please add name of support coordinator/ case mamager/ family member/ NOK

First Name

Last Name

Consent *

This is to acknowledge the client gives permisson for Inclusive OT to accept this referral. Please select Yes from the Option below so that we can process the referral.

Yes

No

One more thing! Safety Screening *

To help our team remain safe, please let us know if any of the following apply

Behaviours of Concern

Behaviour Support Plan in place

History of Substance Misuse

Recent exposure to Covid-19 or any other infectious condition

Antisocial behaviour in the home or neighbourhood

None of the above

Other- add details below