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

Date *

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.

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

Is this a capacity enquiry? *

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

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

Reason for Referral *

Comprehensive Occupational Therapy Assessment

Relevant Medical History *

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

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Capacity Enquiry

Reason for Capacity Enquiry *

Comprehensive Occupational Therapy Assessment

If other please explain *

Funding for the Client *

Aged Care

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 *

Aged Care

Required Start Date of Services *

Proposed End Date of Services *Typically 6-12 months

Invoicing Email *

Funding Body *

Estimated Budget Allocated for Requested Services - $ or hours

Who is the best contact for arranging appointments? *

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

Review by Director

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

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

Aged Care SofS *All time @ $150 p/h

Any further info for Admin?

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 and the bill-to email

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 Case Alert - 4 weeks out, 70% funding used, for 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 SERVICE AGREEMENT

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

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 *

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