Refer a patient under your care for Medicare Occupational Therapy Services

Thank you for choosing Choose Therapy.

Please tell us about the patient under your care so we can provide the best possible assistance.

Our team will reach out to your patient shortly.

Client Information

Full Name *

Date of Birth *

NDIS Number (optional)

Gender / Pronouns (optional)

Address *

Preferred Contact (Phone / Email / SMS) *

Primary Contact (if different)

Relationship to Participant (optional)

Interpreter Required (optional)

Cultural / Communication Preferences (optional)

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 (Optional)

Diagnosis / Conditions

Behavioural or mental health concerns

Mobility status

Communication needs

Current supports (e.g. support worker, psychologist, physio)

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

Preferred Appointment Options (Optional)

In-home assessmentTelehealthCommunity setting

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.

Referrer Name *

Organisation / Role *

Email (Optional)

Phone (Optional)

Date*

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

0430 522 850

choosetherapy@gmail.com

Perth WA Australia

Occupational Therapy Service

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