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1300 0 REHAB (73422)
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Are You Looking for NDIS, Private or Better at Home?
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What Best Describes You?
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Participant
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Local Area Coordinator
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What Best Describes You?
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Participant
Family
Other
Support Coordinator/LAC Details
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Company
Phone
Email
Enquirer Details
First Name
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Email
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Phone
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Relationship To the Participant?
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Father
Mother
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Friend
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Associated
Provider
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Participant Details
First Name
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Date of Birth
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DD slash MM slash YYYY
Phone
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ZIP / Postal Code
Residence Type
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House
Apartment
What Best Describes You?
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Agender
Female
Male
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Rather not say
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Primary Disability
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Acquired Brain Injury
ADHD Attention Deficit Hyperactivity Disorder
Alzheimers Disease
Amputation
Asperger Syndrome
Autism
Behavioural Disorder
Bi Polar Affective Disorder
Blind
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Chromosomal Disorder / Genetic Disorder
CVA
Deaf
Deafblind (dual disability)
Dementia
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Down Syndrome
Dyspraxia
Epilepsy
Foetal Alcohol Syndrome Disorder
Genetic Disorder
Hearing Impairment
Huntingtons Disease
Intellectual Disability
Language Disorder
Learning Disability
Mental Health
Moderate Hearing Loss
Motor Neurone Disease
Multiple Sclerosis
Muscular Dystrophy
Neurological
Neuropathy
ODD
Other Brain Injury
Other Neurological
Other Physical
Other Psychiatric
Parkinsons Disease
Post Traumatic Stress Disorder
Psychiatric
Psychosocial
Rheumatoid Arthritis
Schizophrenia
Scoliosis
Speech and Sound Disorder
Speech Disorder
Spina Bifida
Spinal Cord Injury
Stroke
Substance Abuse
Traumatic Brain Injury
Vision Impaired
Other
Secondary Condition
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Acquired Brain Injury
Adjustment Disorder
Alcohol Related
Alzheimers Disease
Amputation
Ankylosing Spondylitis
Anoxia/Hypoxia
Anxiety
Aphrasia
Arthrogryposis
Asperger Syndrome
Ataxia
Autism
Back Injury
Behavioural Disorder
Bipolar Affective Disorder
Blind
Cerebellar Degeneration
Cerebral Leukodystrophy
Cerebral Palsy
Cervical Spondylitis
Charcot-Marie-Tooth Disease
Conduct Disorder
Congenital Deformity
CVA
Deaf
Deafblind (dual disability)
Dementia
Depression
Developmental delay 0-5 yrs only
Dysphasia
Dyspraxia
Dystonia
Eating Disorder
Epilepsy
Expressive Disorder
Familial Spastic Paresis
Friedreichs Ataxia
Guillain Barre Syndrome
Hearing
Higher Functioning Autism
HIV related Brain Injury
Homocystinuria
Huntingtons Disease
Hyperopia (Long Sighted)
Impulse Control Disorder
Infection
Intellectual inc Down Syndrome
Language Disorder
Mild Hearing Loss
Mixed Receptive/Exp Disorder
Moderate Hearing Loss
Motor Neurone Disease
Multi System Atrophy
Multiple Sclerosis
Muscular Atrophy
Muscular Dystrophy
Myasthenia Gravis
Myopia (Short Sighted)
Neurofibromatosis
Neurological
Neuropathy
Nystagmus
Obsessive Compulsive Disorder
Oppositional Defiance Disorder
Osteo Arthritis
Osteogenesis Imperfecta
Other Brain Injury
Other Neurological
Other Physical
Other Psychiatric
Parkinsons Disease
Personality Disorder
Pervasive Developmental Disorder
Physical
Polymyositis
Post Polio Syndrome
Post Traumatic Stress Disorder
Profound Hearing Loss
Psychiatric
Receptive Language Disorder
Rheumatoid Arthritis
Scheuermanns Disease
Schizophrenia
Scoliosis
Semantic/Pragmatic Disorder
Sleep Disorder
Specific Learning Disability / ADD
Speech
Spina Bifida
Spinal Cord Injury
Spinal Cord Stenosis
Spinocerebellar Degeneration
Strabismus
Substance Abuse
Syringomyelia
THI Assault
THI Home/Recreation Accident
THI MVA
THI Other
THI Pedestrian
THI Work Accident
Tumour
Unknown
Vision
Vision Impaired
VisionTHI Pedestrian
Primary Disability
Primary Concerns or Condition
Potential Risks
Risk of injury or death to the person or others
Homelessness
Substance abuse
Loss of placement (i.e. school, accommodation, day service)
School or Service placement interruption (temporary)
Police/Criminal justice contact
Sexual
Other
Behaviour of Concern
Physical aggression
Verbal outburst
Property Damage
Self-Injurious behaviour
Other
Do You Need An Interpreter?
Yes
No
What Language Do You Mainly Speak At Home?
GP Details
Hospital
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Phone
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Email
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Funding Details
Email
Private Health Insurer
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HCF
NIB
AHM
Bupa
Medibank
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Health Fund Number
Support Coordinator/LAC details
First Name
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Last Name
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Company
Phone
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Email
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NDIS Plan
NDIS Number
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Plan Start Date
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Plan End Date
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How Is the Plan Managed?
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NDIA-managed
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Who Will Sign the Service Agreement?
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Participant
Plan Nominee
Advocate
Guardian
Trustee
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Full Name
Email
Phone
Plan Manager
Company
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Email
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Phone
(Required)
Plan Goals
Reason for Referral
Discipline
(Required)
Occupational Therapy
Physiotherapy
Speech Pathology
Positive Behaviour Support
Exercise Physiology
Allied Health Assistants
Occupational Therapy Service
Home modifications
Assistive technology
Driving assessments
SIL assessment
SDA assessment
Functional assessment
Other
Other - Occupational Therapy Service
Speech Pathology Services
Social skills
Swallowing
Assistive technology
Other
Other - Speech Pathology Services
Physiotherapy Services
Mobility/Mobility Aids
Falls prevention/Balance training
Assistive technology
Hydrotherapy
Improving chronic pain
Improving mental health
Respiratory
Other
Other - Physiotherapy Services
PBS Services
Functional behaviour assessment
Development of behaviour support
Restrictive Practices
Skill Development
Other
Other - PBS Service (Required)
PBS Funding (Required)
Improved Daily Living
Yes
No
Amount $
Improved Relationships
Yes
No
Amount $ Specialist
Amount $ Standard
Exercise Physiology Services
Strength and exercise program
Falls prevention/Balance training
Improving mental health
Improving cardiovascular fitness
Improving chronic pain
Weight management
Other
Other - Exercise Physiology Services
Preferred Time of Day For Appointments (Mon – Fri)
AM
PM
More Details
Who Is the Best Person To Contact For Appointments?
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Accepted file types: pdf, jpg, jpeg, Max. file size: 4 MB, Max. files: 5.
How Did You Hear About Us?
How did you find out about Better Rehab?
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Patient Details
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Phone
(Required)
Email
Address
(Required)
Street
Suburb
State / Province / Region
ZIP / Postal Code
Gender
(Required)
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Male
Female
Intersex
Rather not say
Other
Private Health Insurer
(Required)
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HCF
NIB
AHM
Bupa
Medibank
Other
Member Number
(Required)
RAPT score (1 - 12)
Please enter a number from
1
to
12
.
Acknowledgement
Please acknowledge that you have gained consent and assessed and documented that the patient is medically suitable
Referring Hospital
Hospital
Contact Name
Phone
Email
Additional Information
Surgery Details
Type of Surgery
(Required)
Date of Surgery
(Required)
DD slash MM slash YYYY
Anticipated Discharge Date
(Required)
DD slash MM slash YYYY
Treating Surgeon/Doctor
(Required)
Department
Doctor’s Phone
Patient Medical Details
PHx Patient History?
ADL/Mobility/Safety Alerts
Uploads
Please upload any relevant medical documents
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Accepted file types: pdf, jpg, jpeg, Max. file size: 4 MB, Max. files: 5.
How Did You Hear About Us?
How did you find out about Better Rehab?
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1300 0 REHAB (73422)
