Allied Health Intake Form

Does the participant or their person responsible for the participant consent to this referral being made?

NDIS Number

Funding Type

***If Plan Managed please confirm the Plan Manager Details

Plan Manager's Name

First NameLast Name

Plan Manager's Phone Number

Please enter a valid phone number.Format: 0000000000.

Plan Manager's Email

example@example.com

NDIS Plan Start date

Date

NDIS Plan End date

Date

Does your NDIS Plan have a funding period schedule?

Funding Period Schedule

Rows	Date From (e.g. 01/01/25)	Date To (e.g. 01/01/26)	Funding Amount (available for allocation to IOH services only) e.g. $1000.00
Period 1
Period 2
Period 3
Period 4
Period 5
Period 6
Period 7
Period 8
Period 9
Period 10
Period 11
Period 12

Total Funding Available (For IOH Services only)

Funding available for initial assessment/ongoing intervention by IOH

Minimum 3 hours required. E.g. $2572.91

NDIS Accepted Diagnoses

Non NDIS Accepted Diagnoses

Communication Type

Other

Nominated Advocate - 1

First NameLast Name

Phone Number - Nominated Advocate -1

Please enter a valid phone number.Format: 0000000000.

Nominated Advocate - 2

First NameLast Name

Phone Number - Nominated Advocate -2

Please enter a valid phone number.Format: 0000000000.

Service Agreement Details

Please note the support coordinator if listed will be CC'd into the service agreement submission. Please indicate if you do not want this to occur.

Service Agreement to be sent to

Service Agreement to be signed by

Service Agreement to be sent via

Other

Referrer Name and Company

e.g. John Smith from IOH

Has the Company/Company Representatives Contact Details been provided already in the form above?

Company/Company Representatives Contact Details

First NameLast Name

Phone Number - Company/Company Representatives Contact Details

Area CodePhone Number

Email - Company/Company Representatives Contact Details

example@example.com

Therapy Services Required

Reason for Referral

i.e. Goals and desired outcome. Please provide the NDIS plan or if not available, clearly list the short and long term goals documented in the plan. If this is not available please provide the RFS

Documentation to upload to support Reason for Referral

Reason for Referral Document upload

Intervention Location

Other

For Southern Highlands participants: services will be met from our Ingleburn office and charged for travel accordingly. NDIS services are not being provided from the Braemar office.

Days Preferred for appointments

Time Preferred for appointments

NDIS or Medical Service Providers

Please use the optino below to enter the providers being seen by the client.
If you are able, please provide Category of provider, Providers name, clinic name/location and contact number for the provider.

e.g. GP - Dr John, Westmead Medical Centre, (02) 4900 1001

To add multiple providers. Please click "Add Row" at the bottom to enter numerous providers.

NDIS or Medical Service Providers

Risk Assessment

Prior to visiting a participant at home or meeting them in the clinic, IOH needs to ensure the safety of staff attending the appointment. Please answer the following questions to the best of your knowledge. Please note, IOH cannot accept a referral without completion of the below.

Please confirm, you have attended the participants home prior to completion of this form/risk assessment

Questions - NDIS

Rows	Yes	No	Unsure	Identified Hazards & Recommended Controls
1. Parking - Is there safe, well-lit parking available close to the home?
2. Pathways and surfaces - level, uncluttered, adequate width?
3. Steps and Stairs - non-slip, level surface, solid?
4. Doors are easily opened and unobstructed
5. Access to home - easy access and exit, more than one exit?
6. Pets - adequately restrained?
7. Are there any safety issues associated with the premises or persons residing?
8. Does the participant have any convictions or pending charges for a serious indictable offence? Please note, if Yes, IOH will need to ensure appropriate measures are in place to maintain health and safety of our staff to ensure the participant receives appropriate service from IOH.
9. Is the participant willing to have IOH attendance and involvement in their care/case?
10. Are there any weapons or potential weapons in the house, street, lane or pathways?
11. Who will be participating in the meeting and who else will be in the home at the time of assessment?
12. Does the participant have behavioural support plan? If Yes, Please ensure this is sent with the referral form to IOH Health
13. Do you have any concerns regarding the safety of visitors / guests for the purpose of service delivery or assessment?
14. Has any other formal supports, or health and care staff, raised concerns about visiting this person?
15. Is there a history of missed appointments or DNA? If yes, what can be done to improve attendance?
16. Do the other participants in the appointment or living in the home have any convictions or pending charges for a serious indictable offence? Please note, if Yes, IOH will need to ensure appropriate measures are in place to maintain health and safety of our staff to ensure the participant receives appropriate service from IOH.

*As you have not attended the Participants' Home, IOH requires a separate Risk Assessment form to be completed by someone who has attended the Participants' home.

Please provide details of a contact who has been to the participant's home that can accurately complete a full Risk Assessment prior to our commencement of any service.

Please note, you will also be asked to complete an abbreviated Risk Assessment below to assist our service allocation and commencement.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: 0000000000.

IOH Admin Email

example@example.com

Questions - NDIS

Rows	Yes	No	Unsure	Identified Hazards & Recommended Controls
1. Does the participant have any convictions or pending charges for a serious indictable offence? Please note, if Yes, IOH will need to ensure appropriate measures are in place to maintain health and safety of our staff to ensure the participant receives appropriate service from IOH.
2. Is the participant willing to have IOH attendance and involvement in their care/case?
3. Who will be participating in the meeting and who else will be in the home at the time of assessment?
4. Does the participant have behavioural support plan? If Yes, Please ensure this is sent with the referral form to IOH Health
5. Do you have any concerns regarding the safety of visitors / guests for the purpose of service delivery or assessment?
6. Has any other formal supports, or health and care staff, raised concerns about visiting this person?
7. Is there a history of missed appointments or DNA? If yes, what can be done to improve attendance?
8. Do the other participants in the appointment or living in the home have any convictions or pending charges for a serious indictable offence? Please note, if Yes, IOH will need to ensure appropriate measures are in place to maintain health and safety of our staff to ensure the participant receives appropriate service from IOH.

Considering the above, what are the specific risks in relation to home visiting at the premises and how can these be manage?

If none please indicate N/A

NDIS Service Request

General Service Request (Psychology/Exercise Physiology/Physiotherapy)

Support at Home Service Request

Medicare

Employee Assistance Program (EAP)