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ABN 97 675 435 355

About
Services
Referrals
Our Policies
Contact

ABN 97 675 435 355

About
Services
Referrals
Our Policies
Contact

Referrals

Referrals Support

At Health and Rehab Care, Making a referral is quick and easy with our online referral form.
Alternatively, our support team is more than happy to help by phone 0493 979 252 or email admin@healthandrehab.com.au

We aim to see new clients within 1 week of receiving a referral.

Home Care Package Referral

CLIENT DETAILS

Full Name
Email
Contact
Gender	MaleFemaleOthers
Date of Birth
Primary Address
Next Of Kin Details
What Services Do You Require?	PhysiotherapyOccupational TherapyPodiatry
Details of Condition (Diagnoses, Medical History, and Relevant Reports (Attach below, e.g., GP letters, hospital referrals, imaging)

HOME CARE PROVIDER (HCP) DETAILS

HCP Name
HCP Contact
HCP Invoice Email

REFERRER DETAILS

Referral Name
Company (if applicable)
Referrer Email
Referrer Contact
How Did You Hear About Us?
Attachment: Upload any medical records or discharge summary.

NDIS Referral

Please note we can only see self-managed and planned managed client at this stage.

CLIENT DETAILS

Full Name
Participant Email
Contact
Gender	MaleFemaleOthers
Date of Birth
Primary Address
Living Situation
What Services Do You Require?	PhysiotherapyOccupational TherapyPodiatry
Reason for Referral (Goals, priorities, urgency, equipment)
Details of Condition (Diagnoses, medical history, other relevant reports (attach bellow) e.g. GP letters, hospital referral, imaging)
Next of kin details Please include name, phone, email & relationship to client)
Does next of kin have authority to act on behalf of client?	YesNoUnsure

REFERRER DETAILS

Referral Name
Company/Organisation
Referrer Email
Referrer Contact
Relationship to Participant

NDIS DETAILS

NDIS client Number
Plan start & end date
Hours available for Service? (if applicable)
How are funds managed?
Email for invoices
How Did You Hear About Us?
Attachment: Upload any medical records or discharge summary.

Private Referral

CLIENT DETAILS

Full Name
Email
Contact
Gender	MaleFemaleOthers
Date of Birth
Primary Address
What Services Do You Require?	PhysiotherapyOccupational TherapyPodiatry
Details of Condition (Diagnoses, medical history, other relevant reports (attach bellow) e.g. GP letters, hospital referral, imaging)

Next Of Kin Details

Name
Contact
Relationships to client
Who do we contact for correspondence and appointments?
How Did You Hear About Us?
Attachment: Upload any medical records or discharge summary.

We encourage you to review our services and reach out to us if you have any questions or concerns . Thank you for entrusting us with your care.

AddressUs

PO Box 07, Chirnside Park, VIC 3116

Email

support@healthandrehab.com.au

Reach Us

0493 979 252

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