Referral Form

Step 1

At InOne Healthcare, we are committed to helping you or your loved one achieve your health goals and live your best life.

We take the time to understand each person’s unique needs and aspirations, tailoring our services to deliver the best possible outcomes. We cater to individuals aged 2 years and older.

Our referral form is quick and easy to complete, providing us with the essential information needed to get started promptly.

If you need any assistance or have any feedback, please don’t hesitate to email our team at info@inonehealthcare.com.au.

View our Terms and Conditions.
NDIS T&C
Home Care T&C

To get started please tell us; in which state is this service required?*

in Victroia we currently provide the following HCP, NDIS, Medicare, Workcover and TAC services: Occupational Therapy, Speech Therapy, Physiotherapy, Nursing, Podiatry, Osteopathy
In New South Wales we currently provide the following Homecare and NDIS participant services: Occupational Therapy, Physiotherapy, Podiatry, Speech Pathology
In Western Australia we currently provide the following Homecare and NDIS participant services: Dietetics, Occupational Therapy, Physiotherapy, Speech Pathology
in Queensland we currently provide the following HCP and NDIS services: Occupational Therapy
In South Australia we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Nursing, Occupational Therapy, Osteopathy, Physiotherapy, Podiatry, Speech Pathology
In Tasmania we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Nursing, Occupational Therapy, Osteopathy, Physiotherapy, Podiatry, Speech Pathology
In Australian Capital Territory we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Nursing, Occupational Therapy, Osteopathy, Physiotherapy, Podiatry, Speech Pathology
In Northern Territory we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Nursing, Occupational Therapy, Osteopathy, Physiotherapy, Podiatry, Speech Pathology

Step 2

Referrer (please tell us about you)

First Name*

Last Name*

Position*

Referrers Post Code*

Organisation

Contact Phone Number*

Email*

Step 3

Client Details (about the person to provide care to)

Has this Client been seen by an InOne Healthcare clinician previously? *

Yes

This field is required.

First Name*

Prefers to be called (if different)

Last Name*

Date of Birth*

Gender*

Street Address*

Unit/Flat

Suburb*

State*

Postcode*

Type of Home*

Private Residence

Aged Care Facility

SDA (Specialist Disability Accommodation)

SIL (Supported Independent Living)

SRS (Supported Residential Services)

Other

This field is required.

Notes: Access to Home

Please use this space to provide any instructions we may need regarding access to the client's home.

Step 4

Client Contact Details

Who should be our primary point of contact to arrange client appointments with?*

The Client A Relative or other Representative

This field is required.

Emergency Contact

In the event of an emergency who should we contact?

Name of Emergency Contact*:

Last Name:

Relationship to Client*:

Mobile Number (Preferred):

Other Phone Number:

Home Risk Assessment

Are there any issues you are aware of that may impact on client, carer or service provider safety?

No Yes

If there is a possibility of the client or a family member being aggressive toward the attending InOne Healthcare clinician, a case manager must be present during appointments. Aggressive or threatening behaviour will not be tolerated. If the clinician feels unsafe at any time, they have the right to leave the premises and refuse future treatment.

Step 5

Funding Details

How are the services to be funded?* Home Care Package CHSP / Private Funding / Other NDIS

This field is required.

Step 6

Step 7

Nursing Assessment Required

Please choose at least one of the following*

Medication Management

Administer Insulin / Diabetes Management

Catheter Care

Continence

Wound Care / Management

Other...

Nursing Regularity Required

What is the main reason for the nursing referral?*

Please provide GP Name and Phone

GP Name

Phone*

GP Practice*

Email*

GP Authority

We cannot provide the service you have requested without a signed and dated authorisation from a qualified Doctor (GP or Specialist).

Please provide an authority with this referral. If required, you can access relevant authorisation templates.

Can you provide documentation for GP Authority?*

We require a signed and dated authorisation letter from a GP or other medical practitioner to be able to provide this service. Are you able to provide that approval with this referral?

Yes

No * By submitting this referral without the required authority, you acknowledge that our Nursing team will endeavour to obtain it. This work will be charged at our standard Nursing hourly rate. The minimum cost for this service is $105.00 invoiced in advance. Click here to acknowledge that you accept these terms.

step 8

Medical Details*

Client has no problem communicating verbally.

Client has some issues with verbal communication.

Client requires an interpreter

Client Mobility*

Independent

Supervised

Requires Assistance

Are you able to upload Medical History Files now?*

Examples of acceptable documentation are GP Health Summary, Hospital discharge summary or NSAF (National Screening Assessment Framework). One of these documents is an essential requirement for all nursing referrals.

Yes

This field is required.

Finally, if you have any other documentation you would like to attach

Step 9

Confirmations*

Click here to acknowledge that you have read and accept the relevant terms and conditions of service which you can access below.

Terms and Conditions
NDIS Referrals Terms & Conditions
Home Care Package and Private Funding terms and conditions

Click here to confirm you have obtained verbal/written consent from the client/guardian to refer and provide their personal health information to InOne Healthcare for further assessment.

Step 1

Step 2

Referrer (please tell us about you)

Step 3

Client Details (about the person to provide care to)

Notes: Access to Home

Step 4

Client Contact Details

Please provide at least one contact number:

Please provide at least one contact number:

Emergency Contact

Step 5

Funding Details

NDIS

Step 6

Referral Information

Hydrotherapy Approval

We’ll ask you more about the nursing services required on the next page.

Your Referral

Which of these services are required?*

Step 7

Nursing Assessment Required

Please choose at least one of the following*

Please provide GP Name and Phone

Can you provide documentation for GP Authority?*

step 8

Medical Details*

Client Mobility*

Are you able to upload Medical History Files now?*

Finally, if you have any other documentation you would like to attach

Step 9

Confirmations*

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