Enquiry and referral form

Occupational Therapy Referral and Enquiry Form

Please select if this is an enquiry or a referral *

General EnquiryReferral

Date *

Please outline the main reason for your enquiry: *

What is your name?

Your preferred contact details: *e.g. Mobile number, email

Your relationship to the client: *

GPOther health professionalCare partnerSupport coordinatorFamilySelfOther

Client Details (required if this is a referral)

First Name *

Last name *

Date of Birth *

Address *Include any specifics re parking or access

Email address

Phone number

Primary Contact (if not client)

Name

Phone number

Referral Information

Reason for referral *Clinical reasons for referral, presenting problem, relevant client goals.

Client Medical History

Are there immediate client safety concerns? If you answered yes, please provide details.

Are there any known risks or hazards at the home?E.g. Any anxiety, mood changes, threatening behaviour, smoking, drugs on site, animals, weapons, building safety

Is an interpreter required?What is the primary language spoken at home?

Please note any cultural considerations or preferences that will help ensure the first visit is respectful and comfortable. Leave blank if not applicable.E.g., remove shoes before entering the house; times of day to avoid visits, etc

Please upload any additional relevant information

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Medical history, Care plan etc

Referrer details

Name

Organisation

Phone

Relationship to client above

Has the client consented to this referral? *

YesNoUnsure

How did you hear about Encore OT?

Signature *

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