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0412 366 472

Home
About
Services
Referral Form
Contact Us

Referral Form

Participant's Details

First Name of Participant*

What is the First Name of the Participant?

Telephone of Participant

Please let us know the telephone number of the Participant

NDIS Participant Number if Applicable

Invalid Input

Last Name of Participant*

What is the Last Name of the Participant?

Particpant's Email

Please enter the participant's email

Date of Birth*

Please let us know the client's Date of Birth

Street Address*

Please let us know the Street Address of the participant.

State*

Please let us know what state the participant lives in

Postcode*

Please let us know the clients Postcode

Living Arrangement (with Family, Alone, etc..)*

please let us know the participants living arrangement

NDIS Plan Start Date:*

please let us know the NDIS Plan start date

NDIS Plan End Date:*

please let us know the NDIS Plan end date

List of Disabilities*

please provide a list of disabilities that the participant has

Do they have other conditions?*

Yes No

please let us know if they have other medical history?

Other Conditions

Invalid Input

Support Person

First Name*

What is the support persons first name?

Phone Number*

What is the support person's phone number?

Last Name*

Please let us the support persons Last Name

What is the support person's email?

Is the support person living with the participant*

Yes No

please let us know if the Support person is living with the Participant

NDIS Coordinator

NDIS Coordinator Name

Please let us your First Name

Phone Number

Please let us your Phone Number

Please let us know what your Email is

Preferred Contact

Please contact the...*

Participant Support Person Support Coordinator

Please let us know the preferred contact

NDIS Funding Type

The NDIS funding type is...*

Self-Managed NDIA Managed Plan Managed

please let us know the funding type

Plan Manager Organisation/Name*

Please let us know the Managers Name

Plan Manager's Email*

please let us know the Plan Manager's Email

Please confirm there is funding in the: Improved Daily Living (CB Daily Activity). An initial OT assessment, travel and identification of therapy/functional needs will take 5 hours. Please contact us for quotes for different services available (see list below).*

Yes (5 Hours minimum required)
Unsure / No. Please Contact us before booking

please let us know if there is funding in the sections above

Current NDIS Provider (Name/Type)

Invalid Input

To assist us with ensuring we allocate the most suitable Occupational Therapist for participant, please provide reason for Occupational Therapy Assessment (tick all that apply).*

Skill building (e.g moving out of home, cooking, money skills, travel training, personal care skills)
Assistive Technology – low cost/low risk (e.g. shower chair, toilet seats, adapted kitchen aids).
Assistive Technology requiring prior approval from NDIS (high cost/high risk) e.g. scripted wheelchairs, shower commodes, bed, pressure cushions) . These items involve equipment trials, quotes and OT reports to NDIS.
Comprehensive Functional Assessment and Report (Care needs assessment)
Supported Independent Living / Specialist Disability Accommodation Assessment and Report.
Short Term Accommodation
Unsure
Other

please provide reason for Occupational Therapy Assessment

Other

Invalid Input

Other Information

How Did You Hear About Us?*

please let us know how you found out about us

Other

Invalid Input

Name of Person Completing Form*

please let us know the name of the person completing this form

Confirm Email for Person Completing Form*

please let us know the email of the person who completed this form

Please Attach NDIS PLAN or Goal Sections of NDIS Plan*

Please Attach NDIS PLAN or Goal Sections of NDIS Plan

Contact Details

0412 366 472
(07) 4404 9598

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Location

Servicing Townsvile Region
1 Phantom Place, Mount Louisa
Townsville, QLD, Australia, 4814

Our Mission

Our mission is to provide quality, sustainable and flexible services that uphold human rights and create opportunities, empowering you to live the life you choose.

Queenscare would like to acknowledge the Traditional Owners of the land on which we operate. We pay respect to Elders past, present and future and value the traditions, cultures and aspirations of the First Australians of this land

Our Values and Culture

Person Centred Approach in our services, and creative in our delivery plan.
Care in our relationships, and honest in our conduct.
Accountable in all our work, and responsible for our actions.
Respectful of your choices and embracing of diversity.
Excellent in our work and driven by our vision and values.

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