Our experienced Allied Health Team are here to help you achieve your goals and flourish in every part of your life. Please allow up to 15 minutes to complete our referral form below. There is also an option to save information as you progress and return at a later time (this is located at the bottom of the form).

If you have any queries at all please don't hesitate to contact us on 07 3155 3778 or admin@mytherapycrew.com.au

Upon hitting submit you will receive an emailed copy of the form submitted to us.

Which best describes you? *

I'm new to My Therapy CrewI'm an existing client of My Therapy Crew

Personal Details

First Name *This should be the name of the person requiring therapy

Last Name *

Email Address *

Date of birth *

Sex *

MaleFemaleOther

Phone Number *Please kindly enter in the following format for mobiles 0000 000 000 and 00 0000 0000 for landlines.

Person's name *

Person's Phone Number *The number should be in the following format for mobiles 0000 000 000 and the following for landlines 00 0000 0000.

Street number and street *

Suburb *

State *

Post code *

Is an interpreter required? *

YesNo

Language spoken *

Do any of the following apply? We will require a copy of these for our records PRIOR to any appointments being booked. *

Positive behaviour support plan in place (send us the plan + overseeing practitioner details)Custody, parenting or guardianship ordersMedical response plan (allergy, asthma, seizure management, etc) Not applicable

Attach Document

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Preferred Communication

My primary communication method/s is *

SpeechSignCommunication Device (detail below)Other (detail below)

My communication method is *

We provide a reminder SMS a few days prior to your appointment. Do you opt in to receive this? *

YesNo

Medications

Are you currently taking any regular medications? *

YesNo

Details of medications *

Services Offered

Reason for referral *Please provide detail if referral is for an FCA (ie does the client wish to move, do they need more funding, or do they wish to know areas for potential skill development etc.)

Assistive Technology requirements *

Home Modifications requirements *

My Assistive Technology/Home Modifications budget is *

Agency ManagedPlan ManagedSelf Managed

Please kindly check your NDIS plan when completing this information

I would like my appointments at *

HomeMy Therapy Crew clinic at North LakesEducational setting (eg day program/school/daycare)Telehealth

Educational setting location - Name of setting and suburb *

Do you have any safety concerns at this location that our crew need to be aware of? Eg. pets, hazards, behaviours of concern by both the client or those in the home or setting away from the clinic.

YesNo

If yes, provide further information *

Frequency of Allied Health Assistant *

WeeklyFortnightlyMonthly

Frequency of Counselling services *

WeeklyFortnightlyMonthly

Frequency of Occupational Therapy *

WeeklyFortnightlyMonthly

Frequency of Physiotherapy *

WeeklyFortnightlyMonthlyUnsure

Frequency of Speech Therapy *

WeeklyFortnightly

Please provide the name and phone number of this person. If you have selected Other, please provide the nature of this relationship. eg. Aunt *

Do you have a preference for male/female therapist? *

YesNo

Please provide further details. *Would you consider your non preferred therapist for a short period of time if your preferred therapist is unavailable?

Diagnoses

Please advise when this brain injury was acquired *

Other Diagnoses

Physical disability details *

Date of onset *

Payment of My Services

The services will be paid by *

Medicare - you must have a Team Care Arrangement from your GP to access thisNDISPrivately/Private Health CoverHome Care Package

NDIS Funding Type *

Agency ManagedPlan ManagedSelf Managed

Plan Management Company *

NDIS Information

NDIS Participant Number *

Plan Start Date *

Plan End Date *

My NDIS plan is set up in PACE *

YesNo

What is PACE – stands for Participant/Provider Alternative Cloud Environment – is the NDIA’s new customer relationship management system (CRM). Most big organisations use a CRM to record, analyse and store customer data, and to communicate with their customers. PACE is: - designed to make it easier for NDIA staff and partners to do their job, work the same way everywhere in Australia, and make consistent decisions and intended to improve the participant and provider experience

My NDIS Goals *

Copy and paste belowAttach a copy

NDIS Goals - copy and paste or type in box below *

NDIS Goals as an attachment *

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Email invoices to *

I have a Support Coordinator *

YesNo

Support Coordinators Full Name *

Support Coordinator's Organisation Name *

Support Coordinators Email *

Support Coordinators Phone Number *

Plan Manager Organisational Name *

Plan Manager Email to send invoices to *

Plan Manager Phone Number *

Physiotherapy

Reason for visit *Please bring along any scans/reports to provide to the physiotherapist.

Highlight your areas of concern *

Clear drawing

Music Therapy

What goals would you like to focus on in Music Therapy? *

Have you had previous music therapy services? *

YesNo

Details of Other

As music therapists we like to use client-preferred music as much as we can. Please list some music (songs or artist names) that you enjoy. This can also include TV shows or movies that use music you enjoy. *

Are there any types of music or musical activities you don’t like? *

Positive Behaviour Support (PBS)

My plan has the following behaviour support funding package *

Level 1Level 2Level 3I don't have funding but am looking to provide evidence to gain further funding (My Therapy Crew can offer this via your therapy budget)Unsure - provide further details below

These are the details in my plan - you can also attach an image from your plan to assist with providing funding information and delivering services within your budget and needs. *

Copy of positive behaviour support information from NDIS plan

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Speech Therapy

Speech Therapy Reason for Referral

Please add further details applicable to the YES or UNSURE items above *

Do you have difficulties with eating safely or eating independently? *

YesNo

Historical Information

I provide informed consent that I have listed and provided My Therapy Crew with all relevant history and that is true and accurate *

YesNo

The client has demonstrated previous aggressive behaviour *

YesNo

The client is known to bite or use physical force *

YesNo

Does the client have emotional outbursts or big emotions that others need to help calm *

YesNo

Does the client use any actions or behaviours that may injure others *

YesNo

Does the person use a current alternative and augmentative communication system (AAC) (others ways of communicating other then verbally) and if YES please provide details about what these are e.g. device or application name. *

YesNo

Please provide details about what these are e.g. device or application name. *

Is there any other information you would like us to know? For example you may like to provide us with cultural/religious considerations to be aware of. *

Please attach any other reports or documents you feel would be useful. If you have selected that PBSP, parenting/custody/guardianship orders are in place or medical response plans are in place, please attach here.

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Consent

Providing a safe workplace *

YesNo

The client / client’s guardian consent for staff and contractors of My Therapy Crew to protect themselves from any physical or emotional harm caused by the client during a session.

YesNo

The client / client’s guardian consent for staff and contractors of My Therapy Crew to suspend the session if client becomes physical or emotionally abusive during the session.

YesNo

The client / client’s guardian consent for staff and contractors of My Therapy Crew to administer first aid to client if at all necessary, during the session.

YesNo

Please select Yes or No for each of the following. *

YesNo

I consent that My Therapy Crew can share information internally as required – for example between OTs and Allied Health Assistants.

YesNo

I consent that My Therapy Crew can discuss specifics as needed of my situation with my support coordinator, plan manager or the NDIS (if applicable).

YesNo

I consent that My Therapy Crew can discuss specifics of my situation with other health professionals including but not limited to my GP, psychiatrist, physiotherapist, speech language pathologist, psychologist, or other treating allied health professionals.

YesNo

Photos and Audio *

The client / client’s guardian consent to photos being taken during sessions for the use of internal and external purposes by My Therapy CrewThe client / client’s guardian DOES NOT consent to photos being taken during sessions for the use of internal and external purposes by My Therapy CrewThe client / client’s guardian consent to audio being taken during sessions for the use of internal and external purposes by My Therapy CrewThe client / client’s guardian DOES NOT consent to audio being taken during sessions for the use of internal and external purposes by My Therapy Crew

We will always ask the client or the client’s guardian verbally if they are happy for us to take photos/record audio during the session. Photos/audio are used for a range of reasons including, but not limited to – internal training, demonstrations and social media and marketing purposes. Clients have the right to refuse this at any time.

Staff and Student Shadowing

Our core values - dependable, always learning, nurturing and contributing, support our oranisational vision 'To make a positive impact in the lives of our clients and crew'.

As part of our contributing value we are passionate about our profession and are committed to supportingAllied Health professionals to have a positive impact. We empower ourcrew to share their knowledge and skill.

To support this value we provide opportunities to new staff joining My Therapy Crew to accompany our staff into therapy appointments. These same opportunities are provided to students who are assigned to My Therapy Crew in order to complete their professional placement as part of their university studies. We commonly refer to this as 'shadowing'.

Do you consent to students and new staff onboarding with our team to shadow with your therapist/allied health assistant? If yes, we will record this on your personal records. *

YesNo

If you are completing this form on behalf of someone please provide your FULL NAME, phone number, email and relationship to the person

Other details

Data and Consent

As an allied health provider that provides a health service and hold health information we are bound by the requirements of the Privacy Act 1988 and the collection of health information. The Australian Privacy Principles (or APPs) are the cornerstone of the privacy protection framework in thePrivacy Act 1988. They apply to any organisation or agency the Privacy Act covers.

As per Australian Privacy Principle 3 – we onlycollect personal and health information that is reasonably necessary for our functions or activities. Health information is anypersonal informationabout your health or disability. It includes (but is not limited to) information or opinion about your illness, injury or disability.

Some examples of health information include:
notes of your symptoms or diagnosis
information about a health service you’ve had or will receive
specialist reports and test results
your genetic information
your wishes about future health services
appointment and billing details
any otherpersonal informationabout you when ahealth service providercollects it.

As per Australian Privacy Principle 11 – we takereasonable steps to protect your personal information we hold from misuse, interference and loss, as well as unauthorised access, modification or disclosure.

As per National Privacy Principle 6 –we may use or disclose your personal information for a secondary purpose if the use or disclosure is required or authorised by or under an Australian law or a court/tribunal order (APP 6.2(b)).

How to correct your health information with us

If you think the health information we hold about you is incorrect, please contact us and request we correct it.We may ask you to follow a certain process, such as putting your request in writing.

If we have given incorrect information to others, you may ask us to tell those other parties about the corrections.

In line with the Privacy Act 1988you should expect this to be actioned within 30 days.

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