Modality

Mobile Physio, Dietitian, OT, Drama Therapy and Exercise Physiology Referral Form

Not sure which service you need? Follow this link to understand more about the services we offer: https://southsidephysio.com.au/services/southside-physio/

CURRENT WAIT TIMES (regularly updated):

Physio	1 - 4 weeks wait, depending on availability and location.
Exercise Physiology (EP)	1 - 4 weeks wait, depending on availability and location.
Physio or EP	See above
Occupational Therapy	2 - 4 months, however we have a waitlist in place and are attempting to contact those clients first. Depending on your location and availability, you may be able to commence services sooner.
Dietitian	No wait list - Current appointment availability is approximately one month ahead
LDK Greenway Physio or AHA	No wait list
LDK Greenway Classes	No wait list
LDK Amberfield Physio or AHA	No wait list
LDK Amberfield Classes	No wait list
LDK OT - Greenway/Amberfield	No wait list - Limited capacity.
Drama Therapy	Limited capacity, depending on availability and location.
Remedial Massage	At capacity

Please note that all services referred to through this referral form are MOBILE SERVICES ONLY.

If you wish to engage in a Physiotherapy, Exercise Physiology or Dietitian service in in the clinic, please contact our Woden or Tuggeranong clinic for an appointment (please see southsidephysio.com.au for clinic contacts or use Clinic Referral Form (snapforms.com.au)
Please note that Support at Home clients can be seen through our mobile service only

Please provide as much relevant information as possible - Insufficient/ incomplete referral information requires follow up and may delay the booking of your client's/ your appointment.

Are you: *

The ClientThe Referrer

Date of Referral

Modality Required

Personal and Required Services Information

Referrer's Details

Name of Referrer *

Referrer's Contact No. *

Email address of Referrer *

Referring Company Name, if applicable

Support Coordinator/Case manager (if applicable)

Client Information

First Name *

Last Name *

DOB *

Contact Phone Number *

Does the contact phone number belong to the client? *

YesNo

If no, who is the contact? *

Client Email Address

Steet No. and Name (room number if LDK) *

Suburb *

Postcode *

State *

Who does the participant live with? *

Emergency Contact Name and Number

Relationship to Emergency Contact

How did you hear about us? *

Additional Client Details

* Not all services are able to be covered by Workers Compensation, and each referral will reviewed on a case-by-case basis. Third Party fee schedules are required to match SSPG's fee schedules, including Workers Compensation.

How will the assessment be paid

How will the service be managed? *

Support at HomeShort Term Restorative Care STRC PrivateDVA

Support at Home Details

Support at Home Service Provider Name *

SAH Case manager Contact details (if not referrer)

Please provide best contact name, email address and phone number where we will be sending the assessment invoice? *

NDIS Details

Is your NDIS plan broken up into funding components (e.g. annual, quarterly, monthly) *

YesNo

Funding Period Schedule

Funding Period Start

Funding Period End

Months

Funding Amount

Please tell us the time frame of your funding components (e.g. annual, quarterly, monthly) and how much funding is available per funding component

NDIS Number (if applicable):

Plan Manager Name *

Plan Dates/STRC dates (if applicable):

Budget for service (NDIS/Home care packages):

Please provide STRC program dates:

Claim Number (for Workers Compensation ONLY):

Injury Date (for Workers Compensation ONLY):

Name of Insurance Company (for Workers Compensation ONLY):

GP Name and Clinic *

Case History and Expected Outcome

Diagnosis and brief medical history

Has the client experienced repeated chest infections (2 or more within the last 6-12 months not related to flu/covid etc)?

Does the client cough on food or drinks at all meals?

Has the client experienced multiple choking episodes?

Does the client have an existing swallowing difficulty and their condition is deteriorating?

Patient Goals/Recommendations/Purpose of Referral *

Is this referral for a script for Oral Nutrition Supplements?

What is the earliest date the client can start sessions?

Current level of exercise / exercise history *

Additional Occupational Therapy Information

Are you seeking home modifications? *

YesNo

If you are unsure of the specific home modifications required, we can arrange a 30-minute Care Coordination consultation with one of our Occupational Therapists to provide tailored advice and recommended next steps.

Would you like a Home Modification Care Coordination call? *

YesNo

Note: A 30-minute Care Coordination call will cost $110.00 for Private and Support at Home clients.

For NDIS clients costing will be in accordance with the current NDIS price guidelines

Straightforward changes with a low risk of major problems arising during or after the work is done.

Excludes changes to a bathroom floor.

Don’t require local authority building permission

Budget typicaly $10,000 or less.

Home Modifications: Category A

Temporary or simple ramps (internal or external)Ramp rails or grab railsBathroom changes that don’t affect the floor sub-structureRemoving or changing non-structural items, for example internal doors or shower screensMinor carpentry works, for example adjusting cabinetry or benchesChanging light switches or power pointsDoor wideningDoor automation

Our Occupational Therapy team does not undertake Category B home modifications.

These modifications include, but are not limited to:

Category B modifications are generally low risk of major problems arising during or after the work is done.

Don’t require local authority building permission

Budget typicaly between $10,000 and $20,000

Home Modifications: Category B

Removing a bathtub and installing a walk-in shower with new waterproof flooring
Building a medium-sized ramp (5–8 m) with handrails and surface leveling
Lowering kitchen benchtops and relocating the sink for wheelchair access
Reconfiguring a laundry area, including plumbing and electrical adjustments
Widening multiple doorways and replacing door frames (non-load-bearing)
Combining several small modifications (e.g., bathroom + ramp + doorway) where total cost exceeds $10,000 AUD

Additional Information *

Stairs and Entry Access *

Install stair rail / second handrailStep modification (e.g., contrast striping, edge repair)Step replacement or ramp alternativePlatform lift requiredOther

Additional Information *

Other Home Modification *

Kitchen modifications (e.g., bench height, tapware, storage access)Bedroom modifications (e.g., bed height, ceiling hoist)Lighting or switch adjustmentsPathway or outdoor access improvementsOther

Additional Information *

Risk Assessment

Risk Assement

Risks to our team:

These are questions we have to ask to ensure the safety of our team, participants/clients and patients. Please note any risks in the box below. Please consider these questions carefully.

Is there anything you would like to tell us regarding access to your house, parking, etc?

Will the client and the practitioner be the only people present during treatment?

Will all animals be prevented access to the front of the property or the parts where the practitioner will be? If NO, what animals will be present, and do they pose any risk to the practitioner?

Will everyone in the property refrain from smoking, drinking alcohol or using substances during the visit?

Does anyone in the property have a history of actual or threatened violent/aggressive behaviour?

Are there weapons in the home?

Is there a work area in the property where the practitioner can safely place equipment and work?

Is there stable mobile phone service/coverage?

Is there any risk of infection or illness?

Are there any mental health challenges or considerations we need to be aware of?

Are there any behaviour triggers we need to be aware of? If so, is there a behaviour plan in place?

Are there any cultural considerations you would like us to be aware of?

Are there any other risks we need to be aware of?

Please note any risks here relative to the questions above. Please write NO risks if none exist. *

Any other relevant medical history?

Accounts. Where do we send your invoices? Please provide best contact name, email address and phone number. *

If you (referrer) would like to discuss the appointment prior to the appointment date, please advise our Mobile team by filling out the field below. Please include your best contact details.

Do you have any other important information you would like to provide? (Family/social situation/ EPOA etc)

Please upload any supporting documents here (NDIS PLAN, STRC or SAH summary, medication list, or past medical history)

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