CLIENT DETAILS

First Name *

Last Name *

DOB *

Gender *

Phone Number *

Email Address *

Street address *

Suburb *

State *

Postcode *

Country of Birth *

Language(s) Spoken *

Cultural and Spiritual Considerations

Aboriginal or Torres Strait IslanderCulturally and linguistically diverse background (CALD)Other

Please describe: *

Cultural needs or support preferences:

Religious or spiritual needs:

MEDICAL HISTORY

Do you/individual have any allergies? *

YesNo

Please describe: *

Do you/individual experience seizures? *

YesNo

Please describe: *

Do you/individual have chronic conditions e.g. heart disease, arthritis, diabetes etc? *

YesNo

Please describe: *

Are there any other medical history details e.g. cancer, prone to infections etc. relevant to you/individual supports? *

YesNo

Please describe: *

Do you/individual take any medication? *

YesNo

Please describe (include dosage): *

Do you/individual have any known disabilities? *

YesNo

Neurodevelopmental Disorders

e.g. Intellectual disability, Autism Spectrum Disorder (ASD), Attention deficit hyperactivity disorder (ADHD), Communication disorders, Specific learning disorder, Motor disorders

Physical Disability

e.g. Multiple Sclerosis, Muscular Dystrophy, Chronic Arthritis, Cerebral Palsy, Chronic Fatigue Syndrome, Fibromyalgia, Spina Bifida, Loss of limbs and Spinal Cord Injury

Acquired brain injury (ABI)

e.g. stroke, brain tumours, poisoning, lack of oxygen and degenerative neurological disease

Neurological Disability

e.g. Cerebral palsy, Multiple sclerosis, Parkinson’s disease, Epilepsy and Alzheimers disease.

Vision Impairment

e.g. mild vision impairment to total blindness

Hearing Impairment

e.g. Hearing impairment, hearing loss, or deafness

Deafblind (dual sensory)

e.g. combined vision and hearing impairments

Speech Language Impairment

e.g. Autism Spectrum Disorder, Intellectual Disability, Downs Syndrome, Hearing Impairment, Acquired Brain Injury

Psychosocial Disability

e.g. depression, anxiety disorders, schizophrenia, bipolar disorder

Developmental delay

e.g. physical, emotional, social, communication, thinking skills, difficulties dressing themselves, talk or walk

CLIENT REPRESENTATIVE/EMERGENCY CONTACT DETAILS

Relationship *

Title *

First Name *

Last Name *

Phone Number *

Email *

Street address *

Suburb *

State *

Postcode *

FUNDING DETAILS

NDIS fundedPrivately fundedThird-party funded

Plan *

Plan Managed Self Managed Agency Managed

Plan Manager Name *

Accounts Payable email *

Third Party Funder Name *

NDIS Number *

Start date *

End date *

Accounts payable email *

Please note: we do not have a Medicare provider number for claiming services that are outside of the NDIS.

Consent for NDIS auditor to contact for interview: *

YesNo

Periodic audits conducted by third-party firms may want feedback of our services provided.

Consent for NDIS auditor to review file? *

YesNo

Auditors will have access to your records that we have stored on the participant's file.

THIRD-PARTY REFERRER DETAILS

Are you a third-party referrer? *

YesNo

for e.g. You are a support coordinator or an organisation referring on behalf of the participant.

Title *

First Name *

Last Name *

Agency *

Lookup

Entity Name *

Entity Type Name

Role *

Email Address *

Phone Number *

I have obtained consent from the participant to make this referral and provide Horizon Therapy Services with the participant's personal and medical details.

REASON FOR REFERRAL

Reason for referral *

OCCUPATIONAL THERAPY

Horizon Therapy Services offer various types of Occupational Therapy Assessments. Please review the descriptions below to ensure that you are selecting the correct assessment type(s) to meet your needs. Whilst multiple assessments may be required, it would not be recommended that you select both an Initial Assessment and a Functional Capacity Assessment as these assessments largely cover the same areas but for different purposes. Selecting both types of these assessments would not be the best use of funding*.

Please select up to 3 of the assessments below:

Initial Assessment

The first assessment for a child or an adult who has not attended the clinic before. This assessment includes the assessment of motor skills, sensory skills and generalised living skills.

This option should be selected if:

You want to receive guidance on whether ongoing occupational therapy may be of assistance to you.

As you have selected Initial Assessment, the option to select Functional Capacity Assessment has been removed (please refer to the information provided above*). If you have selected the incorrect assessment, untick Initial Assessment.

Functional Capacity Assessment

An assessment which occurs at the client’s home address to evaluate a person’s needs and support requirements. This assessment can also include recommendations for SIL and/or SDA needs where applicable.

This option should be selected if:

You want to know what level of support worker assistance you may require at home.
You want to know of any low-cost assistive technology which may assist you to live more independently at home.
You want to have a thorough report detailing your current ability to perform tasks of daily living to inform your next NDIS plan review.
You want to receive guidance on whether ongoing occupational therapy may be of assistance to you.

As you have selected Functional Capacity Assessment, the option to select Initial Assessment has been removed (please refer to the information provided above*). If you have selected the incorrect assessment, untick Functional Capacity Assessment.

Are recommendations required for Supported Independant Living (SIL) *

YesNo

Are recommendations required for Specialist Disability Accommodation (SDA) *

YesNo

Home Safety Assessment

An assessment which occurs at the client’s home address to identify hazards within the home and to provide education to the client on how to increase safety. The assessment also addresses daily living skills and levels of independence of the individual. This assessment can also assess for low-cost assistive technology (below $1500.00).

Assistive Technology Assessment

An assessment which occurs at the client’s home address to identify which equipment, technology and/or devices may assist a person to live more independently. This assessment is required for assistive technology items which are likely to cost more than $1500.00.

Equipment required: *Please give an accurate description of assitive technology required

SPEECH PATHOLOGY

Initial Assessment: *

YesNo

A 60-minute assessment for a child or an adult who has not attended the clinic before. This assessment includes investigation of communication concerns specifically speech sounds, language, fluency, social/pragmatic skills, reading and/or writing.

ADDITIONAL INFORMATION

Please provide any further information that would be beneficial for our clinician(s) when preparing for the assessment

AVAILABILITY

Monday