New Client Referral Form

New Client Referral Form

Location of Services *

If other, what location are you in? *

Please detail if specific reports/ services are required:

How did you hear about us? *

Client Details

Client First Name *

Client Surname *

Client Date Of Birth *

Is the Client of Aboriginal or Torres Strait Islander origin?

NoYes, AboriginalYes, Torres Strait Islander

Client Email *

Street address *

City *

State *

Postcode *

The Client/ Representative can be contacted on:

Client Representative Name *

Relationship to Client *

Phone *

Email Address of Client Representative *

Support Coordinator (If different to the Client/ Representative) can be contacted on:

Support Coordinator Name

Support Coordinator Contact Number

Support Coordinator Email

Service Details

Please outline the number of sessions the client is to receive *GP Management Plans allow clients to receive 5 Medicare funded allied health appointments a year, please outline how many are to be utilised by which profession (e.g. 2 x Speech, 3 x Psychology).

Please outline the number of sessions the client is to receive *People of Aboriginal or Torres Strait Islander descent under Care Plans receive 10 Medicare funded allied health appointments a year, please outline how many are to be utilised by which profession (e.g. 5 x Speech, 2 x OT, 3 x Psychology).

What is the appointment type requested? *

NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

NDIS Management *

NDIS Plan ManagedNDIS Self ManagedNDIA Managed

If known, specify total allocated funds to Fly2Health

Referring GP *

Referring GP Email *

Supporting Details & Documents

NDIS Plan OR Goals *

Browse

Aboriginal Health Medicare Care Plan *

Browse

GP Management Plan *

Browse

Previous Therapy and Assessment Reports

Browse

Diagnosis and/or Relevant Medical History *

Home Visit Safety Risk Assessment NOTE: this is mandatory if you request home visits (Only applicable in Perth/WA)

We try to book in appointments at a local clinic/school locations. If you require a home visit, please tick 'Home Visit' below to fill in a Home Risk Assessment form: (ONLY AVAILABLE IN WA)

Home Visit Requested (WA only)

If you answered 'Other' please disclose location

Is there mobile phone coverage at your home?

YesNo

Do you have any history of criminal convictions? This information is collected for the sole purpose of ensuring your safety and the safety of our staff during your visit.

Who shall we contact if no one is home upon arrival? *

Call clientCall next of kinCall support coordinatorCall emergency services

Will there be anyone under the influence of drugs and/or alcohol upon arrival?

YesNo

Are there any animals on the property?

YesNo

Are there any weapons/firearms at the home?

YesNo

Is there anyone in the house with a contagious illness?

YesNo

Does anyone in the home currently smoke?

YesNo

Payments

Fly2 Health Group will seek payment for their provision of support after the support has been delivered. We require payment by direct debit/EFT within 7 days. Please note that our cancellation policy is charged at 100% of the appointment fee for late cancellations and no-shows. We require 72 hours (3 business days) notice to reschedule/cancel appointments.

Invoice Email Address (If NDIS, Plan Manager Email) *

NOTE: All NDIS participants accessing our service require an NDIS Service Agreement.

This link will be sent to you automatically via email once our client services team book you in for an initial assessment appointment.

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