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Client Intake Form

    Client Details

    Person to contact to make appointments

     

    Person responsible for signing documents (if applicable)

     

    Emergency contact

    Phone: *

    Referrer

    Coordinator of supports / Case Manager (if not referrer)

    General Practitioner details

     

    Medical Specialist details

    Yes

    Yes

    Yes

     

    Referral details

    Service(s) required

    Rehabilitation Medicine SpecialistSpeech PathologyExercise PhysiologyPhysiotherapyOccupational TherapyTherapy Aide (in addition to other Neuro Alliance Therapy Service)HydrotherapyDizziness ClinicUpper Limb Assessment And TreatmentMultidisciplinary Tone ClinicNeuromuscular Orthotist

    Reasons for Speech Pathology – please indicate all that apply:
    CommunicationSwallowingMealtime Management Plan


    Communication Problems – please indicate all that apply:
    SpeechVoiceLanguageLanguageCognition


    Priority Areas – does the participant:
    Have concerns regarding their swallowing (recent aspiration)?Have an urgent need for a communication system?Have an increased risk of losing their independence due to poor communication?


    Location Of Services (tick all that apply):
    Neuro Alliance Gym/PoolClient HomeCommunity Gym/Pool - Please Specify





    Reasons for Physiotherapy – please indicate all that apply:
    General PT Assessment (for exercise program, equipment prescription) – please indicate below in location whether centre based or community appointments are requiredMobility review (including client specific manual handling training and protocols)Assessment for hydrotherapy


    General PT Assessment Report Required?
    YesNo


    Priority Areas – does the participant:
    Recent fall or a change in their function or mobilityRecent diagnosis or discharge from hospitalHave a high risk of hospitalisation or injury without PT support


    Reason for Occupational Therapy – please indicate all that apply:
    General OT Assessment (e.g review of activities of daily living (ADL), equipment or home modifications)Functional Capacity Assessment – includes report (e.g funding disputes / identifying care needs)Manual Handling Review (training development and protocols)


    General OT Assessment Report Required?
    YesNo


    Priority Areas – does the participant:
    Have a current pressure injury (bed sores/ulcers)Have equipment which is deemed dangerous or ill fittingRequire significant physical support to transfer e.g out of bed/chairHave a high risk of hospitalisation or injury without OT support

    MondayTuesdayWednesdayThursdayFriday

    AMPM

    Neuro Alliance ClinicHome VisitsOther: Please specify

    Funding source

    iCareCommunity Care PackageNDISOther

     

    Self-managedPlan ManagedNDIS Managed

    NDIS planiCare myPLanDischarge summariesSpecialist reports



    NoYes: Please specify

    NoYes: Please specify

    You will receive acknowledgement of referral being received within 48 hours.