Client *

First Name

Last Name

Main contact person

This should be the person who is responsible for confirming appointments and referral details.

First Name

Last Name

Select OT Service needed *

Select all that apply

OT assessment - Home/ Community

OT assessment- Residential Aged Care Assessment

Assistive Technology/Equipment Assessment

Minor Home Modifications

Complex Home Modifications

Powered Mobility Device/ Scooter Assessment

Wheelchair & Seating assessment

Pressure care risk assessment

Manual handling assessment

Other- please specify below

Location for OT appointments *

Please choose all that apply

Client home

OT Clinic Auburn (stairs)

OT Clinic in Parramatta (fully accessible with elevator)

Telehealth

Equipment Showroom

Aged Care Facility

Referrer Name

Family members, case managers and care coordinators kindly provide your details here

First Name

Last Name

Consent *

I give consent for Inclusive OT to contact the client or preferred contact person to discuss 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 risk