Online Referral Form

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MyOTTasmania welcomes referrals from people within the community wanting to refer themselves to our service or from other professionals wanting to refer people to our service.

We do not accept referrals for high-risk clients or actively psychotic clients. We also do not provide crisis or emergency support.

Please ensure all fields are filled in with the correct details before pressing ‘submit’.

1
Referrer Details
2
Client Details
3
Key Contact
4
Funding
5
Reason For Referral
6
Further Information
Referrer Details
Referral Date *
Name and Title *
Organisation *
Address *
Email *
Phone *
Client Details
Client Name *
Date Of Birth *
Current Age *
Gender *
Pronouns
Address *
Email *
Phone *
Occupation (if applicable)
Key Contact/Primary Guardian
Type Of Contact *
Name *
Phone *
Relationship *
Has the client been before? *
Date last seen? *
Funding
Some services may attract a gap fee, contact us on (03) 6431 8411 to discuss if unsure
Funding Type *
NDIS
Participation Number *
Plan Start Date *
Plan End Date *
How is plan managed? *
Plan Manager (if applicable)
Person/s Responsible for Billing *
Available Funds/Hours for Occupational Therapy *
NDIS Goals
Support at Home Program (SaH)
Does the client have SaH/AT funding? *
Support at Home Information
Commonwealth Home Support Program (CHSP)
Commonwealth Home Support Program Information
Private Health Fund
Fund Name *
Fund Number *
Expiry Date *
Medicare
Card Number
Individual Reference Number (IRN)
Expiry Date
Type Of Referral
Department Of Veteran Affairs Card
Card Number
Expiry Date
Other Funding
Fund Information *
Reason For Referral
Service Type *
Services Requested *
Referral Information *
Further Information
Other Current Therapists / Services engaged with: *
Past Diagnoses *
Is this referral to be used for Insurance or legal proceedings? *
Upload any supporting documentation
Maximum file size: 10 MB
Referrer Details
Referral Date *
Name and Title *
Organisation *
Address *
Email *
Phone *
Client Details
Client Name *
Date Of Birth *
Current Age *
Gender *
Pronouns
Address *
Email *
Phone *
Occupation (if applicable)
Key Contact/Primary Guardian
Type Of Contact *
Name *
Phone *
Relationship *
Has the client been before? *
Date last seen? *
Funding
Some services may attract a gap fee, contact us on (03) 6431 8411 to discuss if unsure
Funding Type *
NDIS
Participation Number *
Plan Start Date *
Plan End Date *
How is plan managed? *
Plan Manager (if applicable)
Person/s Responsible for Billing *
Available Funds/Hours for Occupational Therapy *
NDIS Goals
Support at Home Program (SaH)
Does the client have SaH/AT funding? *
Support at Home Information
Commonwealth Home Support Program (CHSP)
Commonwealth Home Support Program Information
Private Health Fund
Fund Name *
Fund Number *
Expiry Date *
Medicare
Card Number
Individual Reference Number (IRN)
Expiry Date
Type Of Referral
Department Of Veteran Affairs Card
Card Number
Expiry Date
Other Funding
Fund Information *
Reason For Referral
Service Type *
Services Requested *
Referral Information *
Further Information
Other Current Therapists / Services engaged with: *
Past Diagnoses *
Is this referral to be used for Insurance or legal proceedings? *
Upload any supporting documentation
Maximum file size: 10 MB

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