ASK Referral Form - Speech Pathology

Referrer email address (for copy of referral, if required) *

For all sections that do not apply to you, leave blank. The * questions must be answered to complete the form.

Client's First Name *

Last Name *

DOB *

Phone Number *

Client/client's representative email address:

Address *

Reason for appointment/referral *

Who do we contact to organise initial appointments? (name, phone, email) *

Service mode *

Face-to-face (in clinic) Face-to-face (Home visit) *only if client is not suitable or unable to attend clinic due to complexity of condition*TelehealthPhone Education

Client's next of kin (NOK): *

Relationship to client:

Emergency contact phone number *

Medicare number (if eligible)

My Aged Care/NDIS/iCare or Similar package? *

Other Service (i.e. DVLA)

Is this referral for a client on a GP approved Chronic Disease Management plan?

YesNo

NDIS Plan type:

Self-managed Plan managed

NDIS participant number: *

Current plan dates: *

NDIS plan manager details (contact and invoicing) *

NDIS COS name and contact details

Is there enough funding for Speech pathology? *

Yes - Privately paying client Yes - NDIS/icare/HCP (ensure a minimum of 8 hours for initial assessments and Intervention recommendations)

Specific amount of funding/hours for the plan period, if known:

Thank you for confirming the speech pathology funding allocation for this participants plan.

Please note that our speech pathologist will determine how this funding is best used based on clinical reasoning, the participant's goals, and the supports required. This includes decisions around the balance of face-to-face and non-face-to-face time, all of which are essential components of evidence-based service delivery.

If it has been directly specified in the participant’s plan that a certain structure must be followed, please provide a copy or written evidence of this requirement so that we can review it in line with NDIS expectations and our clinical responsibilities.

Please don’t hesitate to reach out if you have any questions or need further clarification. We greatly appreciate your referral.

NDIS Goals *

Primary condition/disability and Known Medical History (*referral will declined if this is not completed accurately*) *

Functioning (details of support needs, degree of independence, vision, hearing, physical or intellectual impairments)

Current GP name and contact details: *

This is not an acute service. If acute changes are noted with client's condition, seek urgent medical attention

Swallowing

Current Diet

Current Fluids

Has the client been downgraded awaiting Speech Pathology assessment?

YesNo

Other important information not listed above regarding client's swallow

Communication

Other important information regarding client's communication

Additional messages or comments

Other Services involved in care

Advanced Care Directives *

Referring agent's name and contact details *

Is client consenting to this referral? *

Is this client currently under the care of another Speech Pathologist? If yes please explain why this referral is being made. *

Client/referring agent/NOK/EPOA signature *

Clear

Please confirm you have read and agree to the terms of engagement, privacy policy and cancellation policy. *

To review our terms of engagement, privacy policy and cancellation policy, please visit out website www.askhealthcare.com.au

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