1300 828 888
enquiry@medilinkhealth.com.au

Call Us

Refer Participants
Online Appointment

Mail Us

enquiry@medilinkhealth.com.au

Home
About Us
Services
Transport Services
House Support
Careers
Contact Us

Home
About Us
Services
Transport Services
House Support
Careers
Contact Us

Book Now

Home
About Us
Services
Transport Services
House Support
Careers
Contact Us
Book Now
Online Appointment
Refer Participant

Home
About Us
Services
Transport Services
House Support
Careers
Contact Us
Book Now
Online Appointment
Refer Participant

Book Now

Refer Participant

Home>
Refer Participant

Refer a Participant to Medilink – Seamless Support Starts Here

Do you know someone in need of disability support?

Fill out our referral form to connect them with Medilink’s caring NDIS provider. Our team offers personalised care and support. Refer a participant today and help empower lives for a brighter future!

ABOUT YOU

Please select what describes you best?

Participant Parent or Guardian Family Member / Next of Kin Support Coordinator Plan Manager Local Area Coordinator Early Intervention Partner Medical Professional Administrator / Power of Attorney

Name

Last Name

Phone Number

How did you hear about MediLink Health?

PARTICIPANT DETAILS

First Name

Last Name

Participant Age

Date of Birth

Participant Email

Participant Phone Number

Participant Address

Suburb

Participant Address - State

Participant Gender

Female: she - her Male: he - him Non-binary: they - them Prefer not to say Other

Does ___ ___ identify as Aboriginal or Torres Strait Islander?

No Yes - Aboriginal Yes – Torres Strait Islander Yes - Aboriginal and Torres Strait Islander

Living arrangements for ___ ___

Alone Family/Partner Supported Accommodation Other

Does ___ ___ require an interpreter?

Yes No

Please indicate the Translator/interpreter or the communication aids required

WHO IS THE PRIMARY CONTACT FOR THE FIRST APPOINTMENT?

Is ___ ___ the primary contact for the first appointment?

Yes No

Additional Contacts

Please list the people that are authorised to receive/sign the service agreement and information regarding services. Note: If you are completing this form on the behalf of the participant, please seek approval from the participant prior to completing this section. If you are a support coordinator and have consent from the client to receive the service agreement please enter your details below. Note: Participants can withdraw this consent anytime by emailing enquiry@medilinkhealth.com.au

Additional Contact Name

Last Name

Additional Contact Phone

Additional Contact Email

Relationship to ___ ___?

PRIMARY DISABILITY / HEALTH BACKGROUND

Please provide detail of the primary disability of ___ ___

NDIS DETAILS

NDIS Plan Number

Plan Start Date

Plan End Date

SERVICES

Primary Allied Health Service Required

Other Allied Health Services Required

Occupational Therapy Speech Pathology Physiotherapy Behaviour Support Early Childhood Intervention

Please Select Services Required

Functional Capacity Assessment Pre-planning or Progress Assessment Initial Assessment and Therapy Plan Therapy Program: delivering therapy Early Intervention Assessment and Planning Assistive Technology and Equipment: excluding AAC AAC: augmentative and alternative communication - Speech Pathology Dysphagia/Swallow Assessment - Speech Pathology Home Modifications: Major or Minor - Occupational Therapy Disability Housing Assessments - Occupational Therapy Manual Handling Review Assessment and Recommendation for PBS Funding Home Safety Assessment Falls Assessment Aquatic Therapy I am unsure

NDIS Funding Please confirm the funding available or hours of service required for the allied health supports requested

Occupational Therapy

Speech PathologyTherapy

Physiotherapy

Behaviour Support

Early Childhood Intervention

GOALS

What are the desired Outcomes/Goals for ___ ___

Please upload your NDIS plan and associated documents here.

Preferred Delivery of Services

At home At school In the community In Clinic - not available in all locations

If it was appropriate for the service required, would you consider telehealth?

Yes No

Preferred Appointment Time, day of the week and time?

BILLING

How is the plan funding managed?

NDIA / Agency Managed Self Managed Plan Managed

SAFTEY & SUBMIT

Are Behaviours of Concern (BOCs) currently being demonstrated by ___ ___?

Sexualised behaviours Physical aggression towards others Verbal aggression Self injurious behaviour Absconding or running away Property damage Repetitive or persistent behaviours causing harm None Do not know

Does ___ ___ demonstrate any of these Risks?

Risk of injury or harm to their person or other Homelessness Substance abuse Loss of placement e.g. school accommodation day service School or Service placement interruption temporary Criminal history Sexual Do not know None

Other behaviours and risks that we need to be made aware of?

Please acknowledge that you believe the information entered on this form is, to the best of your awareness, truthful and accurate.