Client Capacity and Referral Form

If you have submitted an Enquiry that has been accepted,
you have been directed back to this page to complete the Full Referral.
Please change the dropdown below option of "Is this a Capacity Enquiry" to "No - specific Referral" .

The notes on accepting this Enquiry to become a Referral from our Manager are:

{{capacity notes to referrer}}

You have been directed back to this Referral to add or amend the information required as per these notes from our Manager:

{{please describe what further info is required from referrer}}

Date of referral *

Is this a Capacity Enquiry for Services? *

Is this a re-referral for a previous/existing Yellow Door Therapy Services Client? *

Is this re-referral just with new Plan dates? *

Thank you for your NEW CLIENT referral

Thank you for Re-Referring your Client for Services

Have any contact details changed for the Client in the last 3 months? *

YesNo

Are there any risk changes to the environment? *

YesNo

Are there any changes to the Services required? *

YesNo

Client Details

First Name *

Last Name *

Client Known As

Date of Birth *

Age *

Suburb *

Phone number *

Email

Address *

Updated client details

Phone Number *

Email *

Address *Include any specifics re parking or access

If other, please explain *

Please advise of new Service Request *e.g.: FCA, Home Mods, AT

Client Representative

Please fill in if there has been a change in Representative or leave blank if previous Representative recorded is still correct.

First Name

Last Name

Relationship to Client

Phone Number

Email

Referrer details

First Name *

Last Name *

Organisation

Position

Referrer's relationship to Client

Other - please explain

Phone

Email *

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Capacity Enquiry

If other, please explain *

Diagnosis *

Ideal time frame for Services *

Funding Amount for OT *

Enquirer Name *

Enquirer Phone

Enquirer Email *

Home Visit Risk

Are there home visit risks? *

Yes (if yes please elaborate)No

Aggressive/Inappropriate behaviourSubstance abuseEnvironmentalPets

Is there a criminal history? *

Yes (if yes please elaborate)UnsureNo

Any risks identified please elaborate *

Home Visit Risks

Are there home visit risks? *

Yes (if yes please elaborate)No

Aggressive/Inappropriate behaviourSubstance abuseEnvironmentalPets

Is there a criminal history? *

Yes (if yes please elaborate)UnsureNo

Any risks identified please elaborate *

Further Information

Diagnosis *

Other Relevant Medical History *

Other Services Involved *

Social Situations (include living arrangement, social supports) *

Additional Information

Please attach any/all relevant documentation or reports

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Funding Information

The Client/Client's Representative is aware they will need to endorse Yellow Door Therapy Services as a MyProvider with the NDIS *

Client Claim Number *

ICWA Referral Type *

Please upload ICWA Provider Treatment Plan *

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If this is under NDIS funding, Please attach a copy of the current NDIS Plan within this Referral
NDIS Referrals will not be accepted without a copy of the Plan

Please upload a copy of the NDIS Plan *

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Please upload a copy of the New NDIS Plan *

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NDIS Number *

Plan Start Date *

Plan End Date *

Updated/New Plan Start Date *

Updated/New Plan End Date *

Plan Manager Company *

Invoicing Email *

We will claim these invoices on PRODA Portal

New Plan Manager Company Invoicing Email *

Updated Invoicing Email *

Newly Agency Managed so we will claim these invoices on PRODA Portal

Estimated Budget Allocated for Requested Services - $ or hours *

Category for NDIS funding *

Does funding need to be confirmed with a 3rd Party Funder? *

Yes No

If the 3rd Party Funder is ICWA or NIISQ, please change the Funding Source radio button choice above

Please provide contact details for the 3rd Party Funder Claims Officer if known *

If CORE Supports are to be used - please provide evidence of approval *

Send Service Agreement to *

Contact for arranging appointments *

Any other Reports or documents that may assist with Services for the Client

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Capacity Enquiry (Clinical Manager)

This Client is suitable for Referral *

Yes - send referral back with "please complete"No - send polite declineNeeds liaising with Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Thank you - this Referral form will be sent back to the Enquirer

Capacity Notes to Referrer

Notes from Manager about this EnquiryThis text is not sent to enquirer

Name of Enquirer

Liaise via Phone

Liaise via Email

Review by Clinical Manager

NO FUNDS APPROVED:

1. If you need further information and wish to push this form back to the Referrer
- you must check Yes then uncheck Admin to gain the approval for funding for this Client
before changing to "Needs Further info"

2. If you wish to decline
- you must check Yes then uncheck Admin to gain the approval for funding for this Client
before changing your answer from Accept to "Decline"

This Client is suitable for services *

YesNoNeed further info

There is a criminal record with this Client!
(The Referrer answered Yes or Unsure)

If this is uncertain, ask the referrer to investigate. Referral will be rejected if there is a criminal history or the referral is uncertain if there is a criminal history.
Identify acceptable level of risk, including requirement for second staff member to attend initial visit, meet in a neutral community venue, updating admin prior to the visit and upon completion of there are concerns.

Please describe what further info is required from referrer *

If no provide reasoning: *

Admin is to gain the approval for funding for this Client

ICWA Type from Referrer

ICWA Type *Manager confirmation

You may be requesting more hours on the Assessment line given Client complexity.
 Please ensure the Hours box below is updated - as this is automatically sent to the Claims Officer.

Hours for Initial Consultation ($154.05/h)

Total Initial Consultation Cost

Hours for Subsequent Consultation ($120.05/h)

Total Subsequent Consultation Cost

Hours for Extended Consultation 45m-1h ($171.50/h)

Total Extended Consultation Cost

Hours for Extended Consultation => 1h ($228.90/h)

Total Extended Consultation =>1h Cost

Qty of Report ($115.90/report)

Total Report Cost

Please note: Communication is charge in 6 minute intervals Eg: 5 units is 30 minutes

Units for Communication ($23.20/each)

Total Communication Cost

Hours for Travel ($185.15/h)

Total Travel Cost

TOTAL COST

Any further information Team or Admin *

Staff Member Allocated *

Staff Member Email *

Staff Member Phone *

Ideal time frame for providing services *

Admin Funding Request Procedure

Claims Officer details (if known) *Admin alter this field to be an email address only

3rd Party Funding Body

3rd party email address *

Admin Funding Approval Confirmation

Funding approval

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Admin to attach the funding approval - please upload PDF of email or copy paste email (so click reply so the header info shows) and including header information (date and who sent) regarding confirmation of funding

Funding NOT received - referral incomplete

Any other info for Manager (include dates of service approved if known)? *If no response received, or funding declined, please specify here steps taken and all info for Manager to review

Clinical Manager Finalisation

Next Steps *

Admin setup case file in Case ManagerAdmin send SA if NDISAdmin sign & return Provider Plan if ICWA

This is a Private/Health Insurance request and I want a Private Service Agreement sent - for clarity of funding to avoid disputes

Change in Current TherapistThe SA will be setup with the Client's current Therapist, unless stated here to change and to whom

Notes from Manager about this Enquiry

{{notes from manager about this enquiry}}

Flag Notes *

Other Contacts including BillTo *

NDIS Dates of Service *

Dates of Service *

Referrer noted: available hours or dollars for SA

Service Agreement hours *

Send Service Agreement to

NDIS Funding Category

Any other information for Admin

Admin Actions

Checked client doesn't already exist in Case Manager and if not, new client entered into Case Manager *

Always take the funds management type from the NDIS Plan received if different to OT's request

OT nominated

Client Category

Client Claim Number

If ICWA - Workers Comp - choose Workers Compensation as the Category in CM

For All Clients:

Claim number entered (find on additional documents if required)Case details tab - add in Flag Notes - COPY PASTE THE INFO FROM THE "ADMIN: NEW referral" EMAIL TEXTMake sure Assigned to is the TherapistCategory as per Client Category infoMake sure Office selected is Pty LtdContacts tab - add whom requested to contactsContacts tab - add Billto as per the Category of ReferralContacts tab - add OT as per allocation (use the Yokine entry not the LASTNAME entry) - Role: Occupational TherapistContacts tab - add enquiries@ndis (if NDIS)

NDIS New Referral:

Create SA Estimate

New Estimate tab - New Estimate from template
Add in Estimate hours as per Plan (or if what Manager has specified is less, use that number)
Add in Start and Finish Dates as per plan to the Top Description Parent task - and Synch Dates
Save

Manager specified dates of service

Always check if there is a Guardian and ensure the Guardian signs NDIS SA
(If it is a Legal Guardian OTG/PTG please do not add in their email address in the Authorised Client Rep section of the SA, instead send them the Unsigned SA as a PDF through CM, email template "Admin use: SA to Guardian via CM only no SF")

Service Agreement Form

NDIS Funding Category

Send SA to

Service Agreement sent - with nominated OT details from above

Add "Alert: SA not signed" Alert from CM Client Details page flag alert & Asana - and upload/save the Unsigned PDF as it comes through to admin@ to CM with the Prefix UNSIGNED

Subtask made to follow up SA each 7 days in Client's Asana task - include the linkthat comes through on the "NOTE" email comes through to admin@ once SA sent. "YDTS SURNAME FU SA".

REMINDER: When resending SA link to client use the CM template"Admin use: Follow Up SA"

This Client is Self or Agency Managed - please create Asana subtask "YDTS LASTNAME FU PACE ENDORSE" to follow up each 4 weeks, to see if this Client is in PORTAL MyProvider - YDTS - Quick links - View Participants.
Change tag for PACE Endorsed to "Waiting".

Send Accept email will automatically be sent to:

If Category is non NDIS Clients:

Ensure you review the 3rd Party funding confirmation in Manager section

Checked hours above match paperwork received - DVA

Locate the Transaction Reference Number (TRN) on the form: "Signed provider acknowledgment form" from the DVA Portal, and add this to the claim number also (being TRN:123etc), we need this for uploading the Report back into the DVA Portal

Checked hours above match Estimate - Health Insurance

Checked hours above match paperwork received - NIISQ

Checked hours above match paperwork received - WorkersComp

New Estimate tab - New Estimate from template
Add in Estimate hours as per plan in the lines items specified
Add in Start and Finish Dates as per plan to the Top Description Parent task - and Synch Dates
Dates could be(e.g. “16 weeks from now” OR “17/6/22 -16/6/23”)
Save

Manager specified dates of service

For ICWA:

Always take the dates from the official paperwork received if different to OT's request

Checked hours above match proof of confirmed hours received - ICWA

ICWA Type

Checked hours above match Therapy Plan paperwork received - ICWA (If it does not - Stop and Save and Complete later this link and liaise with OT)

Upload Unsigned Treatment Plan to CM - ICWA (no Prefix necessary)

Tick, Sign, Stamp and date Therapy Plan via SIgnNow, then upload to CM with the prefix SIGNED and send to Care Service Coordinator/Claims Officer via CM email template "Signed TP to ICWA"

Finish Setup - ALL Clients

If there is text in the "Notes from Manager about this Enquiry" read only box AND/OR
If there is text that overflows the text field box sizes, please drag the right lower corner down to ensure you can see all of the information. Then copy and paste this into a "Formatted Text" document in CM with the title "EXTRA REF INFO" so that we preserve the text as it may get cut off the Form when it becomes a PDF.

REMINDER: Add Referral PDF (as it comes through on the next email after this form is completed) and any attached documents (or emails in admin@ do a quick search by surname) to Client's CM file

Admin completing this Form

Save and Complete Later