Capacity Enquiry and Referral Form

Propel Occupational Therapy is a team of passionate and experienced occupational therapists, providing specialised services for adults across North Queensland.

We believe that everybody deserves to live their life to the fullest potential.

If you have submitted an Enquiry that has been accepted, you have been directed back to this page to complete the Full Referral. Please change the dropdown option of "Is this a Capacity Enquiry" to "No - specific Referral".

Please note further information required:

{{please describe what further info is required from referrer}}

Area of Service *

Townsville + SurroundsRural + Remote

Is the Client over 18? *

YesNo

If you are a new client, please select 'Yes - enquiry only' below
If you are a returning or existing client please select 'No - this is a specific referral' below

Date *

Is this a capacity enquiry? *

Thank you for your interest with Propel OT.

Unfortunately at this time we are at capacity, and are unable to process your referral. We encourage you to check back with us.

Thank you for your interest with Propel OT.

Unfortunately at this time we are at capacity, and are unable to process your referral. We encourage you to check back with us.

Client Information

First Name *

Last Name *

Known As

Date of Birth *

Phone Number *

Email Address *please enter n/a if unknown

Address *Include any specifics re parking or access

Is there a minimum 5 hours available in funding? *

What is your preferred language? *

Do you require an interpreter? *

YesNo

Do you identify as Aboriginal or Torres Strait Islander? *

YesNo

Are there any cultural considerations that we need to know about? *

YesNo

Referral Information

Have you received Services previously with an Occupational Therapist?

Please provide previous OT's contact details so we can ensure a smooth transition of your care *

Reason for Referral *

Skill Building (e.g., moving out of home, cooking, money skills, travel training, personal care skills).Assistive Technology - low cost/low risk (e.g., shower chair, toilet seats, adapted kitchen aids).Assistive Technology requiring prior approval from NDIS (high cost/high risk) e.g., scripted wheelchairs, shower commodes, bed, pressure cushions). These items involve equipment trials, quotes and OT reports to NDIS.Comprehensive Functional Assessment and Report.Supported Independent Living / Specialist Disability Accommodation Assessment and Report.Other.

If other referral reason please explain *

Primary Diagnosis as recognised by NDIS/Specialists *

Relevant Medical History *

Any reports or documents that may assist with services for the Client

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Capacity Enquiry

Diagnosis of Client requiring Services *

Date of Birth *

Reason for Capacity Enquiry *

Skill Building (e.g., moving out of home, cooking, money skills, travel training, personal care skills).Assistive Technology - low cost/low risk (e.g., shower chair, toilet seats, adapted kitchen aids).Assistive Technology requiring prior approval from NDIS (high cost/high risk) e.g., scripted wheelchairs, shower commodes, bed, pressure cushions). These items involve equipment trials, quotes and OT reports to NDIS.Comprehensive Functional Assessment and Report.Supported Independent Living / Specialist Disability Accommodation Assessment and Report.Other.

If other please explain *

Funding for the Client *

NDIS Self ManagedNDIS Plan Managed NDIS Agency ManagedPrivate

NDIS End of Plan date *

Please enter the MMM Zone for this address if known *MMM is the location Classification as per the NDIS

Enquirer Name *

Enquirer Email *

Enquirer Phone

Enquirer's relationship to Client

Please describe the Client's situation and provide an ideal time frame for receiving Services *

Client Representative

First Name

Last Name

Relationship to Client

Contact Phone Number

Contact Email

Referrer Details

Referrer First Name

Referrer Last Name

Referrer Phone

Referrer Email *

Role

Company Name

The client is self-referred

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Funding Information

Funding Source *

NDIS Self ManagedNDIS Plan ManagedNDIS Agency ManagedPrivate

Has the Client changed funds management?

Yes - new details to be providedNo - same funds management as last Plan

Change in funds management *

NDIS Number *

Please enter the MMM Zone for the Client's preferred address if known *MMM is the location Classification as per the NDIS

Plan Start Date *

Plan End Date *

Plan Manager Company *

Plan Manager Invoicing Email *

We will claim invoices from the PRODA Portal.

Newly Agency Managed so we will claim these invoices on PRODA Portal

Plan Manager Company *

Updated Invoicing Email *

Estimated Budget Allocated for Requested Services - $ or hours

Category for NDIS funding *

Invoicing Email *

If CORE Supports are to be used - please provide evidence of approval *

Who shall we send the Service Agreement to? *

Who is the best contact for arranging appointments? *

If the Client consents, please upload a copy of the NDIS Plan if able

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Risk Factors

If you have answered Unsure or Yes to any questions above please explain the situations *These risks may entail any persons present at the appointments or location, or involved in this Client's care

Propel OT expects that the Referrer will liaise with the Therapist to provide a support person if there are elements of risk for face to face visits for this Client.

Director Review Capacity Enquiry

The Client is suitable for Referral *

Yes - this referral form sent back for completionNo - send polite declineNeeds liaising with Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Thank you - this Referral form will be sent back to the Enquirer

Capacity Notes to Referrer

Name of Enquirer

Liaise via Phone

Liaise via Email

Director Review Capacity Enquiry

This Client is suitable for Services *

YesNoNeed further info

Please describe what further info is required from referrer *

If no, please provide reasoning *

Any further information for the Therapist?

Staff Member Allocated *

Staff Member Email *

Ideal time frame for providing services *

Director Finalisation

Next Steps *

Admin setup case file in Splose Admin add to WaitlistAdmin send Service Agreement - release interim funding of $500 before receiving the SSA backAdmin send Service Agreement - release full funding to Therapist - please choose from list

Further discussion is required, we will attend this with the Therapist - please await Service Agreement instructions

Change in Current Therapist?The SA will be setup with the Client's current Therapist, unless stated here to change and to whom

Service Agreement *

Any further info for Admin?

Ongoing Support or Other amount for SA *Please specify if Hours or Dollars

NDIS Funding Category

Specify MMM Class to use Please alter or describe combo if necessary

Admin Set Up

Admin prompts for setup Client

Admin please add to waitlist in Asana and Splose with basic details

Admin please setup or edit Client in Asana (also add Pending SSA in this step if required)

Admin please setup or edit Client in Splose, (add tag Unsigned SA at this step if required) incl. documents and this completed referral when the workflow email comes through post completion

Admin please include in Splose - Invoicing Details (add NDIS number into "extra invoicing info") and the bill-to email

This Client is AGENCY MANAGED - please assign the Bill-To as NDIA with email of "Bill to Portal"

You can use the Service Agreement's calculations field to make the $ figures easier per MMM location

Please review the Client's address on the MMM Website

MMM Class for Client

Please await further instructions from the Director directly in regards to the Services required for this Client

Please do not attend Service Agreement/Case Budget setup

Admin please create Case Budget
- Please title as SURNAME dd.mm.yy - dd.mm.yy
- Ensure budget in $ figure
- The referral period will be "non standard" and use the End date of Plan as expiry
- Add in Case Alerts - 4 weeks out 70% funding used - notify Therapist

Please make Case Budget for $500 and note the full $ amount to be added/updated when SSA returned in Notes section of Case Budget

LINK TO NDIS SERVICE AGREEMENT

LINK TO PRIVATE/AGED CARE SERVICE AGREEMENT

Admin issued SA to Relevant Party (Client/Client Rep/COS etc)

Send SA to

NDIS Funding Category

Admin create Service Booking in PRODA portal under "CB Daily"

Admin create Service Booking in PRODA portal under "Daily Activities" (CORE)

Admin please add in Support Activity - End of Plan Reminder 6 weeks out into Splose Calendar for main Therapist (and mark as do not invoice)

This is an easy website for calculating the End of Plan date minus 6 weeks

Team member completing this Form *

Save and Complete Later