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.

Client Information

Full Name *

Date of Birth *

Medicare Number*

Gender / Pronouns *

Address *

Preferred Contact (Phone / Email / SMS) *

Primary Contact (if different)

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*

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 *

Phone

Date: 2/3/2026

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