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.

Region *

Townsville and SurroundsRural and Remote

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.

Funding

Please select your Funding *

St John's Other

Please Click Here to access the required form for your referral.

Date *

Client Details

First Name *

Last Name *

Date of Birth *

Contact Number *

Email *

Address *

Street address *

City *

State *

Postcode *

Client Representative Details

First Name

Last Name

Phone Number

Email

Relationship to Client

Referrer Details

First Name

Last Name

Referrer Phone

Referrer Email *

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

Thank you

Please send the Service Agreement to *

Please Liaise with for Appointments *

Thank you for your information.
We will be sending a Service Agreement to you soon for your review and consent.

Review by Director

This Client is suitable for Services *

YesNo

If no, please provide reasoning *

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

Aged Care SofSAll time @ $150 p/h

Any further info for Admin?

Staff Member Allocated

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

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

Send SA to

Admin issued SA to Relevant Party (Client/Client Rep/Funder 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