Menu
0

Please complete this form to register yourself or your client for Soaring Health’s community service. Please include as much information as possible to ensure that we can proceed with making a booking within 48 hours. If any relevant information is missing, we will contact you to obtain this information, but this may delay the booking process.

    • 1

      Referral Details

    • 2

      Request Confirmation

    1/2

    Referral Details

    I am completing this form for*

    Referrer Details

    Full Name of Referrer*

    Referring Organisation Name*

    Referrer's Role in Organisation*

    Referrer's Mobile Number*

    Referrer's Email*

    I have obtained consent and have permission to complete this form on behalf of a participant:*

    Note: You cannot send any confidential information to Soaring Health without obtaining permission from the participant (or participant's legal guardian). We cannot receive or store this information unless you have obtained consent to make this referral.

    Participant Details

    First Name*

    Family Name*

    Date Of Birth (dd/mm/yyyy)*

    Gender*

    Home Address

    Participant Contact Number*

    Participant NDIS Number*

    Does the participant have a legal guardian / nominee?*
    NoYes

    Nominee Details

    Name*

    Relationship to participant*

    Mobile*

    Email*

    Cultural Details

    Participant Country of Birth*

    Does the participant require an interpreter?*

    Language of required interpreter

    Relevant culture or religious considerations(if any)?

    Does the listed participant identify as an Aboriginal or Torres Strait islander?

    Services Request

    Type of primary service required:*

    Please list the service(s) required*:
    Number of hours requested for service ?:


    Type of secondary service required:

    Please list service(s) required*:
    Number of hours requested for service ?:


    Additional service required:

    Please list service(s) required*:
    Hours requested for additional service ?:


    Participant's relevant conditions / disability (please list):

    Participant behaviours or habits requiring special attention (if any):



    Extra information that may assist with preparation for initial appointment:

    Special assessments or therapies required:

    Notes for Practitioners (additional relevant details):

    Booking Details

    Preferred consultation type/s:
    In ClinicIn Home ServiceTelehealthCommunity

    Preferred clinic location:
    Templestowe LowerThomastownCraigieburn
    Preferred community organisation:
    School/kinderRespite CentreCommunity House

    Who should we contact to make an appointment?

    Name:*

    Relationship to participant:*

    Mobile Number:*

    Email:*

    Notes for Reception Staff (if applicable):

    NDIS Information

    Participant’s NDIS Plan Type

    Plan Manager's Name:*

    Plan Manager's Contact Number:*

    Plan manager's email:*


    Please upload NDIS Plan and relevant details (Maximum file size is 5MB)

    Consent

    The participant and those involved in the participant's care have read and understood Soaring Health’s current Cancellation Policy?*

    Note: Soaring Health will charge 100% of the full appointment booking if a cancellation occurs within 48 hours. This cancellation policy may change in line with NDIS guidelines.

    The participant and those involved in the participant's care have read and understood Soaring Health’s current Travel Expense Policy?*

    Note: Soaring Health charges a maximum of 30 minutes for each way of travel. This is calculated from the nearest clinic to the participant’s home and billed at the standard rate of the practitioner. If we have multiple participants in your area, the total travel is divided among participants in the area. Travel charges may change in line with NDIS guidelines.

    Please confirm your referral request. We will proceed with the verification process and call you if we need any further information.

    Form Summary



    Services Required

    Primary Required Service :


    Primary Required Service :


    Secondary Required Service :


    Secondary Required Service :


    Additional Required Service :


    Additional Required Service :


     
     
     
     

    Please prove you are human by selecting the Plane.