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.

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

Emergency Contact Phone

Relationship to Participant

Medicare Details

Medicare Number *

Reference *

Expiry *

Reason for Referral *

Daily Living Skills TrainingOngoing Occupational TherapySensory / Emotional Regulation

If other reasons, please specify

Brief summary of current concerns / referral goals *

Relevant Background

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 *

In-home assessmentTelehealthClinic - 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 *

Organisation / Role*

Email *

Phone *

Date: 20/03/2026

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