Client Referral Form

Streamline your referral and booking: please fill out the form below and attach the required documents.

If you don't have all your forms yet, you may submit your referral form, and then email your documents required (GP referral form, QLD Transport Medical Certificate, Optometrist form, photo of Driver's licence, NDIS plan, any other relevant reports etc), to admin@drivingwell.com.au

Once the Driving Well online referral form is submitted, our Practice Manager will contact you to confirm your appointment.

OUR SERVICE AREA

We are able to provide services to clients within the greater Brisbane region:

- north to North Lakes - south to Ormeau - west to Ipswich - east to Bayside

We can see clients outside of these areas if you meet us at a closer location or see us at Alternate Mobility in Slacks Creek.

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Date of referral

Referral Source

Referrer Details

Name

Organisation

Email address

Phone

Relationship to client

Client Details

Name *

Last name *

Preferred name *

Pronouns *

Date of Birth *

Address *Include any specifics re parking or access

Suburb *Include any specifics re parking or access

Postcode *Include any specifics re parking or access

State *Include any specifics re parking or access

Email *

Phone number *

Other contact person details

Name

Phone number

Medical & Disability

Insurer primary accepted disability

Other relevant medical diagnoses

Funding Information

Participant or Claim number

Start date

Re-assessment / end date

NDIS funding type for “improved daily living”

NDIA managed plan managedself managed

Is this a PACE Plan? *

YesNo

Plan manager name

Plan manager contact number

Plan manager email

Support Coordinator contact number

Support Coordinator

Support Coordinator email

Current goals as stated in client's NDIS plan

Referral Information

Please indicate the reason for assessment. If more than one we will schedule as appropriate.

Select required service *

Medical/disability driving assessmentSenior driver assessmentCommercial driver assessmentLearner or pre-learner driver assessmentDriving with vehicle modificationsPassenger vehicle modifications

Best way to organise appointments with client *eg phone parent, email client, text client

I have other appointments already booked on the following dates within the next month:

Risk Assessment

Has the client been vaccinated against COVID? *

YesNoUnsure

Note: we are happy to see clients who have decided not to have the COVID vaccine

Has the support person/s been vaccinated against COVID? *

YesNoUnsure

Will anyone else be at the house at the time of the assessment? Please list *

Is anyone living at the premises known to be potentially aggressive or violent? *

Are there any firearms at the property? *

Will anyone be smoking during the OT visit? We require a smoke-free environment to provide a service. *

Are there any pets? We have a strict rule that all dogs (including "friendly" dogs), need to be restrained during the OT visit. *

Are there any special instructions for access or parking? eg clear pathway, easy to open door / gate etc *

Is there any difficulty with mobile phone coverage and/or a working land line? *

Documents

Upload Required Documents

The fastet way to book your appointment will be to upload your forms with this referral to Driving Well.

If you don't have these documents yet, please submit the referral, and then email your forms to admin@drivingwell.com.au at your earliest convenience.

Download QLD Transport Medical Certificate