Make A Referral (for all non-NDIS clients) - My Rehab Team

1300 4 MY REHAB | 1300 469 734 info@myrehabteam.com.au

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My Rehab Team is an adult neurological service providing mobile therapy. Our paediatric allied therapy sessions are at Medsana Medical Clinic – Eight Mile Plains. Please contact the Medsana Medical Clinic directly on 07 38524878 for children’s appointments.Please refer to our waitlist and service region map if you have not already. Thank you.

ONLINE REFERRAL FORM (non-NDIS)

Please complete the form below. We will get back to you with an appointment time within 24 hours.

If this is for an NDIS participant, please use the NDIS Referral Form instead.
CLIENT DETAILS:
Name of Client:*
Date of Birth (dd/mm/yyyy)*
DD slash MM slash YYYY
Gender*
Email of Client:

Eg. johndoe@hotmail.com
Best Contact No:*
Alternative No:
Visiting Address:*
For ongoing therapy, please refer to www.myrehabteam.com.au/service-regions to determine if visiting address is in our service region

Street Address Suburb State Postcode
SERVICES SELECTION:
Which Therapy Service/s does the client require?*
- Dietetics
- Exercise Physiology
- Occupational Therapy (OT)
- OT Driving Assessment
- Physiotherapy
- Podiatry
- Registered Nurse (continence assessment/support, wound care etc)
- Social Worker
- Speech Pathology
- Therapy Assistant (incl. soft tissue therapy, massage)
Vehicle used for OT Driving Assessment - type of transmission
- Automatic transmission
- Manual transmission
Does the client expect therapist to bring portable massage table & towels?
*For reasons of hygiene and infection control, prevention of falls and manual handling hazards, our therapists do not use their own treatment table or towels.
- Yes, please be in touch to explain why therapist will not bring table/towel
- No, client will have their own table or have funding to get one
- No, client understands it's safer and equally clinically effective to use the client’s bed
GP Case Conference Coordination for clients that identify as having complex medical needs (liaising with participant’s GP / specialists / allied health professionals / carers / service providers on behalf of the participant and family)*
** only some clients require this service - talk to your therapist for further information ** the service is bulk billed to Medicare (subject to change)
- Decline
- Accept - Please provide the participant’s Medicare Number and Expiry Date
Please provide the participant's Medicare Number*
Please provide the participant's Medicare Individual Reference Number*
Please provide the participant's Medicare Card Expiry Date (mm/yyyy)*
Client diagnosis(es) relevant to this referral and/or reason for services selected:*
After initial session, should we offer ongoing therapy?*
- Yes, based on clinical recommendation
- No, please wait for funding approval
REFERRER:
Name:*
Email (notes/reports will be sent to this address):*
Contact No:*
FUNDING OPTIONS:
Does client have/plan to request a DVA D904 referral from their doctor/specialist addressed to MRT?
Does client have/plan to request Medicare referral from their GP addressed to MRT?
Impt info about Medicare GP referrals (Rebate of $58 x 5 allied health sessions per year)
Unfortunately we are not able to bulk-bill. Medicare requires full payment before sending back rebate. Our pricing: 30 min - $99 | 45 min - $145 | 60 min - $194 | Travel fee may be required if location is >20km from Sunnybank.
- Yes I would like to proceed
- I would like a call to discuss further
Funding source for non-DVA/non-Medicare clients
- Home Care Package (HCP)
- Private funding including clients who plan to claim from their health funds
- Other (please provide details below)
Email for invoicing for HCP clients / details about other funding source
Please provide details of authorised party (e.g. case manager) who can approve funds for therapy requested
Name Phone number Email
We will be in touch with you to collect your payment details before arranging the initial session. Let us know if you have a preferred time for us to call?
Are you planning to claim from your private health fund for the requested service?
We will issue a payment receipt to enable you to make claims directly from your Private health fund (It's a good idea to check your fund's inclusions and requirements beforehand).
Who should the invoice be addressed to?
(If an organisation name is used, GST is applicable)
- Client
- Referrer
Useful details for how MRT can help (e.g. what is the client's preferred frequency, does the client need therapy to start within 2 weeks, etc.)
Our wait times & service regions can be found here Booking Info Page
Does the client require an advocate or interpreter due to a communication or language difficulty?*
Does the client have a strong preference for a particular gender therapist due to cultural, religious, or clinical reasons?*
Any other comments? (IMPORTANT: Let us know preferred appointment times or times to avoid. Also include details on parking availability/directions, pets, home environment, etc)
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About My Rehab Team

My Rehab Team's vision is to help people toward an increased sense of ability and confidence. Our team does this by being multi-disciplinary, mobile at flexible locations and multi-cultural.

Our trans-disciplinary practice ethos ensures seamlessness of care and broadens the skills of our clinicians. By having our clients (expert patients) consulting our team, we are able to evolve with your changing needs.

Our skills in neurological rehabilitation, physiotherapy, occupational therapy, podiatry, speech pathology and dietetics all combine to help ensure our clients receive the best outcomes.

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Services

Rehabilitation
Physiotherapy
Exercise Physiology
Occupational Therapy
Speech Therapy
Podiatry
Dietitian
Psychology
Massage Therapy
Driving Assessment
Paediatric Therapy

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1300 4 MY REHAB | 1300 469 734

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07 3056 3264

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info@myrehabteam.com.au

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