Make a referral with Better Rehab

It's easy to make a booking with Better Rehab. Simply fill out and submit our referral form below and we'll take care of the rest.

Referral form

Step 1 of 20 - Select service

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GCLID

What service are you looking for?(Required)

What best describes you?(Required)

How did you hear about us?(Required)

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)

We send monthly emails to support coordinators announcing our capacity for our various locations. Would you like to receive these?(Required)

Yes - I'd like to receive emails

No - do not email me

Enquirer Details

First name(Required)

Last name(Required)

Phone(Required)

Email(Required)

Relationship to the participant(Required)

Please specify

Care Manager Details

First name(Required)

Last name(Required)

Phone(Required)

Email(Required)

Company name(Required)

Participant Details

First name(Required)

Last name(Required)

Phone(Required)

Email(Required)

Date of birth(Required)

DD slash MM slash YYYY

Gender identity(Required)

Identify as Aboriginal or Torres Strait Islander?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Primary language spoken by participant(Required)

Please specify primary language(Required)

Is an interpreter required?(Required)

Street Address(Required)

Suburb(Required)

State(Required)

Post Code(Required)

Patient Details

First name(Required)

Last name(Required)

Phone(Required)

Gender identity(Required)

Date of birth(Required)

DD slash MM slash YYYY

Street Address(Required)

Suburb(Required)

State(Required)

Post Code(Required)

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 first name

Hospital representative contact last name

Hospital contact phone

Hospital contact email

GP first name

GP last name

GP phone

GP email

Client Details

First name(Required)

Last name(Required)

Phone(Required)

Email(Required)

Date of birth(Required)

DD slash MM slash YYYY

Gender identity(Required)

Identify as Aboriginal or Torres Strait Islander?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Primary language spoken by participant(Required)

Please specify primary language(Required)

Street Address(Required)

Suburb(Required)

State(Required)

Post Code(Required)

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)

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 first name(Required)

Treating surgeon/doctor last name(Required)

Treating surgeon/doctor phone

Patient Medical Information

Is RAPT score known?(Required)

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

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)

Invoicing email(Required)

Plan manager company name(Required)

Plan manager phone(Required)

Plan manager first name(Required)

Plan manager last name(Required)

Service Agreement

Who will sign the service agreement?(Required)

First name of person signing the agreement(Required)

Last 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)

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.

Home Care Package Details

Home care package status(Required)

I have HCP funding and would like to use it

I don’t have HCP and want to look at other funding options

Home care package provider(Required)

Home Care Package level(Required)

Care manager first name(Required)

Care manager last name(Required)

Care manager email(Required)

Invoicing email(Required)

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

Amount ($)(Required)

Improved relationships(Required)

Yes

Standard Amount ($)(Required)

Specialist Amount ($)(Required)

Services Required

Disciplines (select all required)(Required)

Occupational Therapy

Speech Pathology

Physiotherapy

Exercise Physiology

Occupational Therapy Services

Select all required occupational therapy services

Home modifications

Assistive technology

Driving assessments

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

Appointment Location

Appointment location (select all applicable)(Required)

Home and/or SDA

Better Rehab clinic

School

Telehealth

Other

Residency type(Required)

School name(Required)

School representative contact first name(Required)

School representative contact last name(Required)

School representative contact phone(Required)

School representative contact email(Required)

Telehealth invitation email

Other - please specify

Appointment Preference

First name of who will confirm appointment(Required)

Last name of who will confirm appointment(Required)

Days available (select all applicable)(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Monday availability(Required)

Tuesday availability(Required)

Wednesday availability(Required)

Thursday availability(Required)

Friday availability(Required)

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.

Home Care Package Funding Acknowledgement

Payment acknowledgement(Required)

I acknowledge there are adequate funds available to cover the costs associated with the required allied health supports and that if funds are not made available, the client will be responsible for making direct payment to Better Rehab for services provided.

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).

Email copy of referral

Would you like to receive an email copy of this referral?

Yes

Confirm receiving email(Required)