Privately Paid Allied Health Online Referral

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Please note:

If you are claiming Medicare, please submit via the Medicare Referral form

Location

Preferred service location

ORS office
Telehealth
Private residence
Other

Participant Details

Pronoun

Preferred name

Full Name

First

Last

Date of birth

Gender

Phone

Residence type

Residence organisation

Address

Origin

First Nations People
Culturally and linguistically diverse
N/A

Interpreter required

Communication preferences or requirements

Access requirements

Advocate and Guardian Information

Referrer Information

Referrer Type

Organisation

Phone

Contact name

Referrer Email

Referrer address

Diagnosis and Background

Diagnosis details

Documentation

Please provide a copy of any relevant previous allied health and medical reports, if available. You can also upload photos or screenshots of any additional documents here.

File Upload

Click or drag files to this area to upload. You can upload up to 25 files.

Accepted file types: .xlxs, .jpg, .jpeg, .doc, .docx, .pdf, .png
Max Upload: 25mb.
Please Note: If you encounter upload issues, please remove the affected file/files and retry uploading.

Risks and Safety

Are there any court orders applicable? e.g., parole, apprehended violence order etc.

Has the participant ever been physically aggressive towards allied health, medical or support staff?

Has the participant been incarcerated in a prison, juvenile detention centre or spent time in a forensic hospital for a violent or sexual offence?

Is the participant currently engaging in alcohol or drug use?

Are there any known risks for visiting the participant in their own home?

Is there any other information we need to know about the client? e.g., are there any topics that may trigger the client to become upset? Any specific likes or dislikes?

Initial Assessment

Who do we contact to arrange an appointment?

Who will be present at the appointment?

Initial appointment address

Appointment preferences

Preferred time
No preference

Are there any preferences for a consultant?

Disclaimer

I agree that ORS will charge 100% of the scheduled service price if ORS is not contacted 2 business days before the appointment date for any changes or cancellations. If an appointment is cancelled/rescheduled prior to 2 business days before the appointment date, ORS will not charge a cancellation fee.

Service Agreement

Payment Method

Further Information

How did you hear about ORS?

Disclaimer

ORS will attempt to contact the nominated person in the referral from as soon as the referral has been processed to schedule an appointment at the earliest and most convenient time. If we are unable to contact you via telephone and you have indicated a preferred appointment day and time when completing the referral, we will do our best to schedule at, or around this time and send you an SMS and email with these details. If no appointment day and time were indicated on the referral form, we will need to make contact to confirm a suitable day and time for the appointment and will send you an SMS and email which can be responded to outlining preferred days and times. If we do not hear back from you within ten business days after attempting our first contact, we will be required to close the case to make space for other clients requiring ORS Services.

Disclaimer

I agree that I have obtained the participant's consent to submit this referral form to ORS for processing.

Privately Paid Allied Health Online Referral

One minute application!

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