Private Referral Form

Choose Therapy - Occupational Therapy Services

Thank you for choosing Choose Therapy!
Please complete the referral form below as best as you can so we can understand your client's needs and provide the best possible service for them. If you need help completing this form, please email info@choosetherapy.com.au or call 0430 522 850.

Client Information

First Name *

Last Name *

Date of Birth *

Street Address *

Suburb *

State *

Postcode *

Phone Number *

Email *

Emergency Contact Name (if different)

Emergency Contact Phone Number

Relationship to Participant

Medicare Details (If Eligible)

Medicare Number

Reference

Expiry

NDIS Plan Details (If Eligible)

NDIS Number

NDIS Plan Type

Funding Allocation Amount

Plan Start Date

Plan End Date

Plan Manager Name / Organisation

Plan Manager Email / Phone

Support Coordinator Name / Organisation

Support Coordinator Email / Phone

Reason for Referral *

Daily Living Skills TrainingFunctional Capacity AssessmentOngoing Occupational TherapyAssistive Technology AssessmentsHome & Living Assessment (SDA/SIL/ILO)Environmental ModificationsSensory / Emotional Regulation

If other reasons, please specify

Brief summary of current concerns / referral goals *

Relevant Background

Diagnosis / Concerns *

Behavioural or mental health concerns

Safety considerations (e.g. falls, aggression, infection risk)

Preferred Appointment Options *

In-home assessmentTelehealthCommunity setting (e.g., school, workplace)Clinic - Belmont Office

Preferred days/times

Consent & Privacy

By submitting this referral, I confirm that:

I have the participant's consent to share this information with Choose Therapy.
All details provided are true and correct to the best of my knowledge.

Participant / Referrer / Guardian Name *

Email *

Phone *

Date: 20/03/2026

*I confirm that I have read and agree to the consent statements above

Refer yourself for Occupational Therapy Services for Your Needs