Referral Form

Referrer Full Name*

How Did You Hear About Us

Google

Website

My Allied Health Clinician or GP or Specialist

A friend

Referrer Phone*

Referrer Email*

Client Full Name

Client Email

Client Phone

Client Postcode

Reason for Referral*

Funding *

NDIS

Aged Care Package

Self Funded

Medical Diagnosis

Does the Client have a GP referral

Yes

No

File upload

Type of Assessment Required

Social Work

OT Driving Assessment

OT Functional Capacity Assessment

OT Housing Assessment

OT Wheelchair or Scooter Assessment

OT Ergonomic Assessments

On going therapy

Additional Information

"I confirm that the information provided is accurate and that the individual consents to this referral."

Signature

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Date

Day

Month

Year

In person Consult hours: Monday-Thursday

Telehealth (face to face) hours:

Monday -Friday 8am-4pm

Phone: 1800 402 124

IMPORTANT: Our 1800 number is not used for third party verification services i.e. Eftsure. For administrative or verification enquiries, please contact your client directly for authorised business contact details.

Email: admin@otwellnessgroup.com.au

Locations:

Newcastle OT consult room: Suite 211, 99 Pacific Hwy Charlestown (by appointment only)

Mobile OT and Social Work in your Community

Telehealth (online face to face) Australia wide

Our Office is closed on Weekends and Public Holidays

The OT Wellness Group acknowledges the traditional custodians of the sovereign lands that we work and live on. We pay our respects to their elders past and present.

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