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(02) 7201 8213
Make a booking with Better Rehab
It's easy to make a booking with Better Rehab. Simply fill out and submit the form below and we'll take care of the rest.
Step
1
of
16
- Select service
6%
What service are you looking for?
(Required)
Select option
NDIS
Private
Better At Home (rehab in the home post surgery)
What best describes you?
(Required)
Select option
Participant
Family member
Support coordinator
Local area coordinator
Other
How did you hear about us?
(Required)
Select option
Google
Social media
Word of mouth
Event
Live nearby an office
Currently involved with Better Rehab
Previously involved with Better Rehab
Other
Please specify
Support Coordinator/LAC Details
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Company name
(Required)
Are you the participant's primary support coordinator?
(Required)
Select option
Yes
No
Enquirer Details
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Relationship to the participant
(Required)
Select option
Spouse or partner
Parent or guardian
Grand parent
Child
Grandchild
Related family member
Friend
Coworker or employer
Other
Please specify
Participant Details
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Date of birth
(Required)
DD slash MM slash YYYY
Gender identity
(Required)
Select option
Female
Male
Agender
Non-binary
Transgender
Other
Rather not say
Identify as Aboriginal or Torres Strait Islander?
(Required)
No
Yes, Aboriginal
Yes, Torres Strait Islander
Primary language spoken by participant
(Required)
Select option
English
Mandarin
Arabic
Cantonese
Italian
Vietnamese
Greek
Other
Please specify primary language
(Required)
Is an interpreter required?
(Required)
Select option
Yes
No
Home address
(Required)
Street Address
Suburb
State
Post code
Patient Details
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
Gender identity
(Required)
Select option
Female
Male
Agender
Non-binary
Transgender
Other
Rather not say
Date of birth
(Required)
DD slash MM slash YYYY
Address
(Required)
Street Address
Suburb
State
Post code
Personal information acknowledgement
(Required)
Please acknowledge that the patient consents to this referral and understands that any personal and health information will be shared with the member’s health fund and any authorised agents, as applicable, for the purpose of funding confirmation and facilitation of the program. All parties involved are bound by strict obligations of confidentiality and privacy.
Consent acknowledgement
(Required)
Please acknowledge that you have gained consent and assessed and documented that the patient is medically suitable
GP and Hospital Details
Hospital name
Hospital representative contact name
Hospital contact phone
Hospital contact email
GP first name
GP last name
GP phone
GP email
Participant Details Continued
Participant risks
(Required)
None
Risk of injury or death to the person or others
Homelessness
Substance abuse
Loss of placement (e.g. school, accommodation, day service)
School or Service placement interruption (temporary)
Police/Criminal justice contact
Sexual
Other
Please specify risks
Participant behaviour(s) of concern
(Required)
None
Physical aggression
Verbal outburst
Property damage
Self-injurious behaviour
Other
Please specify behaviours
Consent acknowledgement
(Required)
Please acknowledge that you believe the information entered on this page is, to the best of your awareness, truthful and accurate.
Participant Primary Disability Details
Primary disability type
(Required)
Neurological
Progressive neurological
ASD
Intellectual / developmental disability
Physical
Sensory (sight, speech, sound)
Psychosocial
Genetic
Neurological disabilities (select all that apply)
Brain injury - acquired
Brain injury - traumatic
CVA
Epilepsy
Stroke
Neurological other
Other neurological disabilities - please specify
Physical disabilities (select all that apply)
Amputation
Cerebral Palsy
Down Syndrome
Dyspraxia
Muscular Dystrophy
Paraplegic
Quadriplegic
Rheumatoid Arthritis
Scoliosis
Spina Bifida
Spinal Cord Injury
Physical other
Other physical disabilities - please specify
ASD disabilities (select all that apply)
Asperger Syndrome
Autism
ASD other
Other ASD disabilities - please specify
Intellectual / developmental disabilities (select all that apply)
ADHD
Developmental Delay
Fetal Alcohol Syndrome Disorder
Intellectual Disability
Learning Disability
Intellectual / developmental other
Other intellectual disabilities - please specify
Sensory disabilities (select all that apply)
Blind
Deaf
Deafblind (dual disability)
Hearing Impaired
Speech and Sound Disorder
Speech Disorder
Vision Impaired
Sensory Other
Other sensory disabilities - please specify
Psychosocial disabilities (select all that apply)
Behavioural Disorder
Bipolar Affective Disorder
Mental Health
ODD
Post Traumatic Stress Disorder
Psychiatric
Psychosocial
Rheumatoid Arthritis
Schizophrenia
Substance Abuse
Psychosocial Other
Other psychosocial disabilities - please specify
Genetic disabilities (select all that apply)
Chromosomal Disorder
Down Syndrome
Genetic Disorder
Genetic Other
Other genetic disabilities - please specify
Progressive neuro disabilities (select all that apply)
Alzheimer's Disease
Dementia
Huntingtons Disease
Motor Neurone Disease
Multiple Sclerosis
Parkinson's Disease
Progressive neuro other
Other progressive neuro disabilities - please specify
Participant Secondary Disability Details
Secondary disability type (select NA if not applicable)
(Required)
NA
Neurological
Progressive neurological
ASD
Intellectual / developmental disability
Physical
Sensory
Psychosocial
Genetic
Psychosocial secondary disabilities (select all that apply)
Behavioural Disorder
Bipolar Affective Disorder
Mental Health
ODD
Post Traumatic Stress Disorder
Psychiatric
Psychosocial
Rheumatoid Arthritis
Schizophrenia
Substance Abuse
Psychosocial Other
Further information secondary disability
Patient Condition
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 name
(Required)
Treating surgeon/doctor phone
Patient Medical Information
Is RAPT score known?
(Required)
Select option
Yes
No
RAPT score
(Required)
PHx patient history
(Required)
ADL/mobility/safety alerts
(Required)
Current ROM
(Required)
Current mobility
(Required)
Medical documents
Max. file size: 2 MB.
NDIS Plan Details
Hidden
RETIRED Participant NDIS number
Participant NDIS number
(Required)
Plan start date
(Required)
DD slash MM slash YYYY
Plan end date
(Required)
DD slash MM slash YYYY
While not mandatory, uploading the NDIS plan and/or past reports improves the quality of our service. All information is strictly confidential and only used to support our clinicians in providing personalised care and advice.
Most recent NDIS plan
Max. file size: 2 MB.
Previous report(s)
Max. file size: 2 MB.
Plan Management
How is the plan managed?
(Required)
Select option
NDIA-managed
Self-managed
Plan-managed
I'm not sure
Invoicing email
(Required)
Plan manager company name
(Required)
Plan manager full name
(Required)
Plan manager phone
(Required)
Service Agreement
Who will sign the service agreement?
(Required)
Select option
Participant
Plan nominee
Advocate
Guardian
Trustee
Other
Full name of person signing the agreement
(Required)
Phone of person signing the agreement
(Required)
Email of person signing the agreement
(Required)
Insurance Details
Private health insurer
(Required)
Select option
HCF
NIB
AHM
Bupa
Medibank
Other
Please specify
(Required)
Health fund number
(Required)
Our team will get in touch with you to discuss any potential out-of-pocket expenses you may incur.
NDIS Goals
This information is important to ensure our clinicians structure the service to meet the needs and goals of each participant.
Reason for referral – what do you hope to achieve with Better Rehab’s help?
(Required)
NDIS plan goals (please indicate NA if not relevant)
(Required)
Is there anything else you need from Better Rehab to further meet your goals?
Services Required
Disciplines (select all required)
(Required)
Occupational Therapy
Speech Pathology
Physiotherapy
Exercise Physiology
Positive Behaviour Support
Occupational Therapy Services
Select all required occupational therapy services
Home modifications
Assistive technology
Driving assessments
SIL assessment
SDA assessment
Functional assessment
Other
Home Mods - please specify what is required
(Required)
Other - please specify
Speech Pathology Services
Select all required speech pathology services
Social skills
Swallowing
Assistive technology
Other
Other - please specify
Physiotherapy Services
Select all required physiotherapy services
Mobility/Mobility Aids
Falls prevention/Balance training
Assistive technology
Hydrotherapy
Improving chronic pain
Improving mental health
Respiratory
Other
Other - please specify
Exercise Physiology Services
Select all required exercise physiology services
Strength and exercise program
Falls prevention/Balance training
Improving mental health
Improving cardiovascular fitness
Improving chronic pain
Weight management
Other
Other - please specify
Positive Behaviour Support Services
Select all required positive behaviour support services
Functional behaviour assessment
Development of behaviour support
Restrictive practices
Skill development
Other
Other - please specify
Improved daily living
(Required)
Yes
No
Amount ($)
(Required)
Improved relationships
(Required)
Yes
No
Standard Amount ($)
(Required)
Specialist Amount ($)
(Required)
Appointment Location
Appointment location (select all applicable)
(Required)
Home and/or SDA
Better Rehab clinic
School
Telehealth
Other
Residency type
(Required)
Select option
House
Apartment
SDA
Other
School name
(Required)
School representative contact name
(Required)
School representative contact phone
(Required)
School representative contact email
(Required)
Telehealth invitation email
Other - please specify
Appointment Preference
Name of who will confirm appointment
(Required)
Days available (select all applicable)
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Monday availability
(Required)
Select option
Anytime
Morning
Afternoon
Tuesday availability
(Required)
Select option
Anytime
Morning
Afternoon
Wednesday availability
(Required)
Select option
Anytime
Morning
Afternoon
Thursday availability
(Required)
Select option
Anytime
Morning
Afternoon
Friday availability
(Required)
Select option
Anytime
Morning
Afternoon
Additional information or preference regarding appointment times
Private Funding Acknowledgement
Payment acknowledgement
(Required)
I acknowledge I am responsible for making direct payment to Better Rehab for services provided, and that it is my responsibility to coordinate with my insurance provider to reclaim any eligible funds.
NDIS Funding Acknowledgement
Better Rehab charges an hourly rate set by the NDIS. Based off the services you have selected, the minimum required hours for the first appointment is:
Please review the following consent acknowledgements and tick all boxes to confirm you understand.
Minimum time acknowledgement
(Required)
I understand the minimum hours required shown above is an indicative figure, and may require more depending on travel, report writing, and liaising with coordinators and other clinicians.
Plan funding
(Required)
I confirm to the best of my knowledge that the NDIS plan has enough remaining budget to cover the minimum hours indicated above.
Travel KM acknowledgement
(Required)
I understand travel KMs may be charged per the NDIS guidelines.
Appointments in the home or community are charged for Kilometers (KMs) travelled by clinicians in-line with NDIS price guidelines,
see NDIS pricing arrangements for more details (link opens in a new tab).
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