New Client Referral

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

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. 

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

Child's Details

Parent/Guardian Details

Emergency Contact/Next of Kin

Primary Emergency Contact Person
First and Last Name
Best contact number.
Must be over the age of 18.
Secondary Emergency Contact Person
First and Last Name
Best contact number.
Must be over the age of 18.

My Health Information

Select all that apply.


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


Accounts and Billing Information

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

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To assist with setting up our records for online claiming with Medicare for your reimbursement under the care plan, please complete the following Medicare information for the child:

For Medicare online claiming for children, we require the following information for the parent/caregiver on the same Medicare Card as the child:

NDIS Participant

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Agency Managed Participants: Neuro Alliance will claim via the NDIA Provider or PACE portals for your services. Neuro Alliance are a registered NDIS Provider for participants aged over 7 years. 

Please note , if your child is aged less than 7years and you wish to proceed with referral to Neuro Alliance, you will need to change your funding managment to either Plan Managed or Self Managed prior to engagement in services. 

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

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

LTCS Participant

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

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iCare/Workers Compensation/Insurance

Referral Details

Please outline your diagnosis and treatment requirements.

Cerebral Palsy

Paediatric Amputee and Limb Difference

Stroke

SCI (Spinal Cord Injury)

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Brain Injury

Genetic Syndromes

Down Syndrome

Developmental Delay

Charcot-Marie-Tooth Disease (CMT)

Services Requested

Physiotherapy

NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Occupational Therapy

NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Speech Pathology

NDIS Plan funding will be claimed from the Capacity Building Budget of the client's NDIS Plan.

Exercise Physiology

Hydrotherapy

Appointment Preferences

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

Appointment Location Preferences

Neuro Alliance Paediatrics prefers to complete initial appointments in the clinic with the child and parent wherever possible. 

Prior to an initial assessment, a phone consult will be arranged for the parent/guardian and the allocated clinician. This helps gather important information prior to your child and clinician's first meeting, and allows you to speak freely with your child's clinician about their strengths and challenges, behavioural considerations, and goals to enhance engagement at initial introduction.

Name of community gym/pool; day program provider and location etc.

Home Details

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

Childcare Centre Details

School Details

Additional Details - Child

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Additional Details - Child and Family Supports

Parent/Carer:

Please read the following statements and select the answer that most reflects your current situation. 

Additional Documentation

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. 

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