Client Referral Form

Streamline your referral and booking.

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

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Date of referral

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

Select required service *

Assistive Technology - wheelchair/scooter

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

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 name

Support Coordinator contact number

Support Coordinator email

Current goals as stated in client's NDIS plan

Service agreement information

Steps with the service agreement:

Our practice manager will develop a service agreement, including the anticipated costs and steps required to support you / your client to work towards their goal.
The service agreement needs to be reviewed by the Participant and signed, confirming that there are sufficient funds in the "Capacity Building: improved daily living" budget.
If applicable, we will send the signed service agreement to the plan manager and support coordinator, to confirm that there is sufficient funding available.

Running out of Funding:

We are a small business with quality staff and a lot of operating costs - we cannot run our business if invoices are not paid because you have "run out of funding". We don't get funding from anywhere else.

Consider this:

would you go to the doctor and not pay your bill?
would you go to the hairdresser and not pay your bill?
would you go to Woolworths and not pay for your groceries?

If you / your client signs the service agreement confirming sufficient funds, but these are not available, then it will be the client's responsibility to pay the invoice.

We will issue invoices after each part of the service is delivered (that is - after your initial assessment, after your report, after any further consultations, stages of your funding application).

Core funding

Please note that we CANNOT change our invoice to bill from Core - the OT code from Core funding is for "Disability Health related supports" only, and driving and vehicle modifications are not eligible for this - this only relates to things like urgent pressure care supports. We also understand that this code will be removed as of June 2025.

We will not be able to proceed with the next stages of your service (including commencing and release your report and/or application), until all invoices are paid in full.

Agreement *

I am the Participant and understand these terms.I am a family member of the Participant and understand these terms.I am the Support Coordinator and will ensure my Participant understands these terms.

Note: you can obtain an estimate of fees that may be required for your service on our website - s croll down to "Sample Quote / Schedule of Supports (NDIS Participants), and select the service that you require (driving assessment / driving assessment & vehicle modifications / passenger vehicle modifications / potential to drive (learner drivers), to see the estimated fees involved.

Medical/Disability Information

Insurer primary accepted disability / impairment

Other relevant medical diagnoses

Level of function? *

Stable for last 3 - 5 years (or more)Condition is getting worseCondition is getting better

Type of sitter *

Hands-free sitter (can sit on the edge of a bed and lift both hands)Hands-dependent sitter (can sit on the edge of a bed but need to hold on with at least one hand)Dependent sitter (unable to sit without support)

Current wheelchair (make and model); year that you received this; who prescribed this?

Why are you getting a wheelchair or scooter? *

Do any of these posture and body mechanics situations apply to you? *

Do you need any parts for your wheelchair that are not "off-the-shelf" or that needs to be hand made?Do you have scoliosis or kyphosis?Is one side of your pelvis higher than the other?Is one side of your pelvis twisted?Does your your pelvis tip forwards or backwards more than normal?

If we feel that your seating needs are more complex, we may refer you onto a specialist wheelchair/seating therapist for assessment and management.

Booking information

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

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? *

Are there any court orders? If so - please provide relevant information. *

Documents

Upload Required Documents

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

NDIS / PACE Plan

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Other reports

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(eg discharge summary, specialist letter, OT report)

Photo of client in wheelchair (front view)

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Photo of client in wheelchair (side view)

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Consent

I consent to the Personal and Health Information Collection Statement

*

I consent Driving Well's precautions involved to manage COVID-19 risk

*

Full name *

Authorised to give consent as *

Date *

Signature *

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