Hidden Connections Referral Form.

Welcome!

Thank you for taking the time to complete this referral form.

Please note: This is only a referral form and is used by Amy to determine whether she is most appropriately suited to provide Occupational Therapy support to you through Hidden Connections. Completion of this referral form is used as a triaging tool for Amy and she will then be able to advise on next steps for appointments, waitlists or referral to another service.

Hidden Connections offers services in-clinic (located within Flourish Health Group - 5 Beaumaris Parade, Highett, Vic, 3190) and over telehealth.

Amy currently only works on Monday, Tuesday and Friday.

If you have any further questions or concerns, you are encouraged to please reach out to Hidden Connections via email at admin@hiddenconnections.com.au

Client Information.

First Name *

Last Name *

Preferred Name

Pronouns

Gender *

Date of Birth *

Mobile Number *

Email Address *

What funding model are you under? *

Private NDIS - Self ManagedNDIS - Plan ManagedOther

**Please note, Hidden Connections is unable to accept NDIS Agency Managed clients**

Best Contact Method *

PhoneEmailOther

Who is completing this referral form? *

Yourself (client)Someone else

Referrer Details.

Name of Referrer/Person Completing Form *

Referrer Relationship to Client *

Parent/GuardianSupport CoordinatorHealth Professional Other

Referrer Organisation *

Referrer Mobile Number *

Referrer Email Address *

Who is best to contact regarding the referral? *

ReferrerClientOther

Please confirm that you have received consent from the client to being referred to Hidden Connections *

YesNo

Reason for Referral.

Medical/Health Condition/s *

Referral Reason *

Do you require a Functional Capacity Assessment Report? *

YesNoUnsure

Is this referral related to any ART matters? *

YesNoUnsure

Is this referral related to support to try and access the NDIS? *

YesNoUnsure

Hidden Connections cannot guarantee access to the NDIS however, we can assist in providing reports/evidence to support your NDIS application

Have you been recommended to Hidden Connections by anyone? *

Preferred Mode of Therapy *

In-ClinicTelehealthCombinationUnsure

By means of completing this referral form, you consent to your details being stored on a cloud based healthcare practice management system *

Yes

Save and Complete Later