New Client Referral

Please complete this form to refer for services with Neuro Alliance.

If you experience any difficulties completing this form, please contact our reception desk on 40811899, and ask to speak to one of our Referral Coordinators for assistance.

Who is making this referral? *

Referrers name: *

Referrers contact number: *

Email Address: *Please enter email accurately. On submission of this form a copy of the referral will be forwarded to this email address for your records.

Client Information

Title *

First Name *

Last Name *

Date of Birth *

Gender *

Other Gender - please specify: *

Street address *

City *

State *

Postcode *

Mobile Number *

Secondary Contact Number

Email Address *

Automated appointment reminders will be sent to the email address provided in the above field.

Emergency Contact/Next of Kin Details

Name *First and Last Name

Phone number *Best contact number.

Relationship to client *Spouse, parent, friend etc

My Health Information

GP Name: *

GP Practice Name/Location: *

GP Phone Number: *

Neurologist: *

Rehabilitaion Medicine Specialist: *

ENT: *

Pain Specialist: *

Details of Other Specialist: *

Are you currently engaged with any of the following Allied Health professionals? *Select all that apply.

Physiotherapists Name: *

Physiotherapist Business Name: *

Occupational Therapists Name: *

Occupational Therapist Business Name: *

Speech Pathologists Name: *

Speech Pathologist Business Name: *

Exercise Physiologist Name: *

Exercise Physiologist Business Name: *

This information is useful for communicating with your multi-disciplinary team to ensure a coordinated approach to your care.

Accounts and Billing Information

Please advise if you are under any of the following Schemes: *

DVA

Please submit with this referral a copy of your D904 form from your GP. You can do this using the file upload option below, or alternatively email a copy of your referral to clientsupport@neuroalliance.com.au

DVA Card Type: *

DVA Card Number: *

Expiry Month *

Expiry Year *

Upload a copy of your DVA GP Referral (D904) here:

Browse

GP Referral/ Chronic Disease Managment Plan

GP Referral/Chronic Disease Management Plan patients: Please provide a copy of your GP referral, Chronic Disease Managment Plan and EPC Approval (if applicable) with this referral using the file upload option, or email the document/s to clientsupport@neuroalliance.com.au

Please upload your GP referral here:

Browse

To assist with setting up your file for online claiming with medicare for your reimbursement, please complete the medicare information for the client:

Medicare Number

Individual Reference Number (IRN)

Medicare Expiry - Month: *

Medicare Expiry - Year: *

NDIS Participant

NDIS Participant #: *

NDIS Plan Start Date *

NDIS Plan End Date: *

Please list your plan Goals here: *

If you have a copy of your current NDIS plan, and are happy to provide this to Neuro Alliance, please upload here:

Browse

My Plan is: *

Plan Managed Participants: please provide your plan managers name and contact email for invoicing.

Plan Manager Name: *

Plan Manager Email Address to send invoices: *

Self Managed Participants: Invoicing and communication regarding your accounts for services will be sent directly to you via the email address provided in the Client Information section of this form.

Do you have a Coordinator of Support (COS)? *

COS Name: *

COS Organisation/Business Name

COS Email Address: *

COS Phone Number: *

Home Care Package (Aged Care)

Home Care Package Level (if known):

Name of provider who manages your Home Care Package? *

Provider phone number: *

Provider Email Address:

Neuro Alliance will contact your HCP Provider to request approval for Initial Assessment using your package funding, prior to arranging any appointments.

LTCS Participant

Participant Number: *

Case Manager Name: *

Case Manager Email Address: *

Neuro Alliance will contact your Case Manager to request approval for Initial Assessment.

If you have a copy of your current My Plan it is appreciated if you can provide a copy of this.

Browse

iCare/Workers Compensation/Insurance

Claim Number: *

Insurer: *

Case Manager: *

Case Manager Email: *

Referral Details

Details of Other neurological or complex rehabilitation needs: *Please outline your diagnosis and treatment requirements.

Past Medical History - Details: *

Parkinson's Disease

Year of Diagnosis and Disease Stage: *

Current medical treatment (PD Medications): *

Do you experience any of the following motor complications: *

Unpredictable 'on/off' stateDyskinesiasNone of the above

Do you experience freezing when walking? *

Do you experience any of the following (select all that apply)?

Do you experience issues with your Speech? *

Do you have any concerns with your swallow? *

Please describe your swallow concerns: *

In the last 6months, how many falls have you experienced? Please provide details. *

Do you anticipate any equipment requirements for the home or community access? *

Please provide details of equipment needs: *

Are you interested in participating in Neuro Alliance's PD Warrior Group? *

Multiple Sclerosis

Date of MS Diagnosis: *

MS Subtype: *

Please indicate which of the following apply to you (select all that apply): *

Do you anticipate any equipment requirements for the home or community access? *

Please provide details of equipment needs: *

Do you experience any dizziness or vestibular symptoms? *

YesNo

Please provide details of dizziness or vestibular symptoms: *

Do you have any pressure / seating / positioning concerns? *

YesNo

Please provide details of pressure / seating / positioning concerns: *

Are you interested in participating in Neuro Alliance's MS Get a Head Start program? *

Stroke/TIA

Date of Stroke and hospital discharge? *

Type of Stroke: *

Location of Stroke? *

Please provide details about your stroke and impacts on your function: *

Do you use equipment currently for transfers / mobility? If yes, please provide details of equipment or support needs. *

Do you have upper limb impairments? *

YesNo

Are you able to pick up and drop a washcloth onto a table 3 times? *

YesNo

Do you have any sensation changes? *

YesNo

Please provide details of sensation changes: *

Do you experience any dizziness or vestibular symptoms? *

YesNo

Please provide details of dizziness or vestibular symptoms: *

Do you have any pressure / seating / positioning concerns? *

YesNo

Please provide details of pressure / seating / positioning concerns: *

FND (Functional Neurological Disorder)

Please select all that apply to your FND Presentation: *

Movement difficulties/challengesSpeech concernsPainOther - please specify

Please describe your movement difficulties or challenges. *

Please describe your speech concerns. *

Please describe your Pain. *

Other - Please specify: *

SCI (Spinal Cord Injury)

Level of Spinal Cord Injury (eg. C5) *

ASIA Impairment Level (if Known):

Date of SCI and date of discharge from hospital? *

If you were discharged from hospital in the last 18months, please provide a copy of the rehabilitation discharge summary.

Browse

Have you been linked in with the Hunter Spinal Cord Injury Service? *

YesNo

If yes please provide names of your Allied Health Team (Physio/OT) at Hunter Spinal Cord Injury Service (HSCIS): *

Do you experience impaired respiratory function as a result of your SCI? *

YesNo

Do you have any pressure / seating / positioning concerns? *

YesNo

Please provide details of pressure / seating / positioning concerns: *

Brain Injury

Brain Injury *

Year of injury or diagnosis? *

Do you experience issues with your Speech? *

Have you been linked in with the Hunter Brain Injury Service (HBIS)? *

YesNo

If yes please provide names of your Allied Health Team (Physio/OT) at Hunter Brain Injury Service (HBIS): *

Motor Neurone Disease (MND)

MND Type:

Year of Diagnosis? *

Do you experience any of the following (select all that apply): *

Stumbling due to weakness of the leg musclesDifficulty holding objects due to weakness of the hand musclesSlurring of speech or swallowing difficulties due to weakness of the tongue and throat musclesCramps and/or muscle twitching (fasciculation)None of the above

Do you experience issues with your Speech? *

Do you have any concerns with your swallow? *

Please describe your swallow concerns: *

Please use this section to provide additional details of your MND Presentation: *

Huntington's Disease

Date of diagnosis and disease stage: *

Do you know your CAG repeat? If yes, please provide.

Please indicate which of the following apply to you (you can select more than one) *

Reduced exercise capacity and enduranceImpaired motor control, planning and sequencing of tasksImpaired balance and mobilityHistory of fallsChanges to respiratory functionProblems with chewing and/or swallowingNone of the above

Do you experience issues with your Speech? *

Do you have any concerns with your swallow? *

Please describe your swallow concerns: *

Do you have any pressure / seating / positioning concerns? *

YesNo

Please provide details of pressure / seating / positioning concerns: *

Genetic Disorder

Select your diagnosis: *

Other Genetic Disorder - please specify: *

Alzheimer's Disease/Dementia

Type: *

Please indicate which of the following apply to you (you can select more than one) *

Reduced exercise capacity and enduranceImpaired motor control, planning and sequencing of tasksImpaired balance and mobilityHistory of fallsChanges to respiratory functionProblems with chewing and/or swallowingNone of the above

Do you experience issues with your Speech? *

Amputee and Limb Difference

Date of amputation and discharge from hospital: *

Level (side) of amputation: *

Does the client have a Prosthesis? *

YesNo

Who is your Prosthetist? *

Does the client use a mobility aide for transfers and walking? *

YesNo

Please describe. *

Services Requested

Physiotherapy

Reason for Physiotherapy Referral (select one or more): *

General Physiotherapy Assessment (for exercise programs and equipment prescription)Mobility assessment/Review (includes manual handling training and protocols)Assessment for HydrotherapyAssessment for appropriateness for Neuro Alliance Gait Lab Program

Physiotherapy concerns - Are any of the following applicable to you (select all that apply): *

Recent fall Change in function or mobilityNewly diagnosed medical conditionRecent hospital admission due to your diagnosisHigh risk of hospitalization or injury without Physiotherapy supportNone of the above

Please provide any information relevant to your referral for physiotherapy: *For example: current function/mobility/transfers and details of these concerns; mobility aids/equipment in use; details of falls - frequency/location/injuries sustained.

Do you experience significant levels of pain? *

If possible, please describe your pain.

Please outline your goal/s for Physiotherapy: *

Funding in $ or Hours available for Physiotherapy in NDIS Plan: *NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Occupational Therapy

Reason for Occupational Therapy Referral (select one or more): *

General OT assessment (eg. review of activities of daily living (ADL), equipment or home modifications)Functional Capacity AssessmentManual Handling ReviewSeating Clinic/Assessment

Occupational Therapy concerns - are any of the following applicable to you (select all that apply): *

Current pressure injury (bed sores/ulcers)Dangerous or ill-fitting equipmentRequire significant physical support to transfer (eg. out of bed/chair)High risk of hospitalization or injury without OT SupportNone of the above

Please provide any information relevant to your referral for occupational therapy: *For example: current function/mobility/transfers and details of these concerns; mobility aids/equipment in use; details of falls - frequency/location/injuries sustained.

Do you experience significant levels of pain? *

If possible, please describe your pain.

Please outline your goal/s for Occupational Therapy: *

Funding in $ or Hours available for Occupational Therapy in NDIS Plan: *NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Speech Pathology

Reason for Speech Pathology referral (select one or more): *

CommunicationSwallowingMealtime Management PlanAAC Lab

Speech Pathology concerns -are any of the following applicable to you (select all that apply): *

Recent aspiration/concerns regarding your swallowUrgent need for a communication systemIncreased risk of losing independence due to poor communicationNone of the above

Please provide any information relevant to your referral for Speech Pathology: *For example: current communication devices or concerns with these if relevant to referral reason; details of swallow concerns; details of any recent aspiration events.

Please outline your goal/s for Speech Pathology: *

Funding in $ or Hours available for Speech Pathology in NDIS Plan: *NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Exercise Physiology

Preferred location of Exercise Physiology services (select all that apply): *

Neuro Alliance Gym/Pool exercise programClients home/home exercise programCommunity gym/Pool program

Please specify community pool/gym location: *

Please outline your goal/s for Exercise Physiology: *

Funding Available in $ or Hours for Exercise Physiology in NDIS Plan: *

Funding is from: *

Hydrotherapy

I am interested in (choose 1 or more): *

1:1 hydrotherapy with a Physiotherapist1:1 hydrotherapy with an Exercise PhysiologistGroup Hydrotherapy at Neuro AllianceHydrotherapy in the community

Choose the option you think most represents your ability to access the Neuro Alliance Hydro Pool: *

Please specify preferred Hydrotherapy facility in the community: *

Please outline your goals for Hydrotherapy: *

Funding in $ or Hours for Hydrotherapy in NDIS Plan: *

Funding for Hydrotherapy from: *

Upper Limb Therapy

Reason for Upper Limb Therapy referral: *

General UL assessmentUL Therapy Program - in clinic or homeConstraint Induced Movement Therapy (CIMT)

Please provide any information relevant to your referral for Upper Limb Therapy: *For example: current function, other details relevant to this referral, description of equipment concerns.

Do you experience significant levels of pain? *

If possible, please describe your pain.

Please outline your goals for Upper Limb Therapy: *

Funding in $ or Hours for Upper Limb Therapy available in NDIS Plan: *Upper Limb Therapy is provided by our specialist Occupational Therapists or Physiotherapists. NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Appointment Preferences

To assist us with finding the most appropriate appointment options for you, please let us know your preferences:

Name of contact for appointments: *

Phone number of contact person for appointments: *

Preferred Time for appointments - select one or both: *

AMPM

Preferred location of appointments - select all that apply: *

Neuro Alliance Clinic/PoolHome visitsOther

Please specify other preferred location: *Name of community gym/pool; name of school; day program provider and location etc.

Are there any safety concerns or special considerations at the clients home/residence? *

YesNo

Please provide details of concerns or considerations at the home:

For Home Visit appointments, a Community Risk Screen will be completed prior to confirming your appointment.

Person Responsible for signing documents: *

Client signs themselves:

Please note: Service Agreements and consent forms etc requiring signatures will be sent to the email address provided in the client details section of this form.

If other, please provide the name and email of this person: *

Additional Information and Documentation

Does the client have any behavioral concerns we should be aware of? *

Please describe behaviour concerns: *

Please upload a copy of Client's Behaviour Managment Plan - if applicable.

Browse

Please use the upload buttons below to provide additional supporting documentation for your referral.

Examples of documentation to support your referral include, but are not limited to:

Hospital Discharge Summary
GP Management Plans
Specialist Letters or Reports
Recent Reports and handover documentation from other healthcare professionals.

Browse

Please use this space to list any other information you feel we should know to assist us in processing this referral here: