Care Managers Email *Please allocate the email that will be the best point of contact for us to send reports and other client based correspondence to.

Date of referral *

Referral Organisation

Client Details

Is your client currently receiving services with Summit?

YesNo - new to Summit

If you select yes, previously recorded details about your client will not be requested. Reducing time to complete this form.

Please select funding stream first

Client Funding Stream *

HCPCHSPPrivateSTRC

Level of care

NDIS Plan Manager

Plan Manager Email

Private Paying Clients Email Address

Have you discussed the cost of service with the Private Payer?

Yes - I've discussed the costs required to be paid to Summit with the private payer.No - The private payer is not aware of the costs involved for the Summit service.

Purchase Order Number for selected servicePlease enter the purchase order number for the service above so that we can include it in our invoices. If your organisation does not require one please ignore this section.

STRC Program Dates (start to finish dates)

MBI required?

YesNo

Title *

Name *First and Last Name here please. Our clinical software does not recognize (in bracket names). Please type in legal name.

Date of Birth *

Preferred name

Phone number *

Address *If this address is outside ACT ie Yass, Golburn, Braidwood, Batemans Bay area etc, we will discuss with you travel charges.

Is this client outside ACT/Queanbyean Area? *

YesNo

Please approve travel funding - [$147.88 /hr] *

YesNo

Primary / Emergency Contact

Name *

Phone number *

Is the primary contact the person we call to book appointments? *

YesNo

Referral Information

Urgency of referral *

UrgentNon- Urgent

Reason for urgency

Reason for referral *Place here client care plan needs and goals discussed with client that Summit Health may support with.

Additional information about the client OR the referred serviceFor example: Who should we contact to arrange the service if not the client directly? What are their contact details? Will a translator be required? Do we require two staff with us?

Client Medical History *Medical history impacting on clients mobility and independence which supports this referral.

Client PersonalityAny anxiety, mood changes, threatening behavior. This is for the safety of Summit Health Staff

Animals at the home

Allied Health Services

Please indicate the allied health service required. If more than one we will schedule as appropriate. All prices below include travel ACT and surround. Details about each service are available on our website as a downloadable PDF.

Nursing

Initial RN Assessment : Comprehensive Clinical Assessment & report at the clients home [$280]

Hospital Discharge RN Assessment : Comprehensive Clinical Assessment & report at the clients home [$280]

Does this client require a PAS or RUDAS Assessment? *

Yes No

The additional RUDAS or PAS Ax will incure additional $60 to the initial assement cost. Total cost for initial plus RUDAS or PAS = $340.00

The initial clinical assessment will cover a general overivew of the clients health and wellbeing. The RN will create a Nursing Care Plan and recommend any additional services or support that are required.

The RN will discuss with the Client , NOK and Care Manager if follow up assessments are necessary such as - Diabetic Managment plan, Cognitive Assessment (RUDAS or PAS or KICA).

Do you have a wound care plan from the GP *

YesNo

Wound Care Order by GP or Specialist

Browse

Other issue

Care Plan for Client *

Browse

GP Letter or Hospital Discharge Notes

Browse

Ongoing Nursing Service Rates:

Registered Nurse: Clinical treatment carried out at the clients home or via telehealth [$120.00]

Enrolled Nurse: Clinical treatment carried out at the clients home or via telehealth [$90.00] the enrolled nurses complete their tasks inline with the RN's initial assessment and care plan.

GP Name *

GP Clinic Phone *

GP Clinic Name and Address *

Clinic Email Address

Physiotherapy

NDIS Physiotherapy 15_055_0128_1_3 Physiotherapy assessment and sessions within the clients home or clinic [$193.99 per session ]

NDIS Physio 01_721_0128_1_3 Physiotherapy assessment and sessions within the clients home or clinic [$193.99 per session ]

Occupational Therapy Assessments

Reduced capacity to provide NDIS OT Assessments at this time of update.

Summit Health currently not taking any NDIS referrals for OT Ax.

Occupational Therapy Home Assessment :Home modification ax & report at the clients home [$812.00] includes a report for builders where required. This report shall include simple home modifications and equipment recommendations where relevant. If you're client has recently recieved HCP this is the ideal assessment for them.

Funding approval for potential Equipment Trial (post Home or Equipment Assessment on request from OT) - [$202.95] *

YesNo

Upon completion of the Home or Equipment Report our OT shall recommend if a Simple OT Equipment Trial is required for the client. We are asking up front if the client has funding for this trial to go ahead so that we may stream line the scheduling of trial. A complex trial may be required of which our admin will contact you about.

Does the client have funding for complex trial if required - [$406.00 - 2 hours of trial ] *

Yes No

A complex trial may be required for multiple pieces of equipment, clients with high care needs requiring increased time to transfer in and out of equipment ie a mobility scooter, wheel chair, bed, amputee. Our OT's shall state reason for requesting Complex Trial in their reports.

Occupational Therapy Equipment Assessment: Equipment ax at clients home [$406.00] Non-fixed items only for Equipment Assessment (grab rails, ramps are considered Home Assessments)

Telehealth option for OT assessment *

Yes - this is urgent and we would prefer the assessment completed as soon as possible even via TelehealthNo - Client is willing to wait for the assessment to be conducted with OT face to face.

Telehealth assessments are conducted in the clients home with a qualified Occupational Therapist via Zoom with our trained Allied Health Assistant who is a OT student in their final year supporting the OT to conduct the session. The client will see the OT on the screen and talk directly with them. Please note all OT Equipment Trials are conducted face to face with therapist in the equipment show room or in the clients home.

CHSP - Occupational Therapy Assessment

CHSP Full OT Assessment : A more indepth full home ax & report at the clients home [$812.00] includes a report for builders where required. (Please select this option if your company has requested the full home from Summit Health).

Physiotherapy and Allied Health

Initial Functional Mobility Assessment

Our Allied Health Professional Team will create a clinically justified report supporting a Wellness or Reablement approach. They may then recommend ongoing sessions including AHA Physio Exercise Sessions and or AHA Physio.

Initial Functional and Mobilty Assessment: Initial consultation & report at clients home [$202.95 per assessment ] by our Allied Health Professional team.

Social Worker

Initial Social Woker Assessment and Report

The initial social work assessment provides a clear snapshot of your client’s emotional wellbeing, social supports, mental health, and home environment. It explores family and caregiver dynamics to identify any signs of stress or care breakdown. The report outlines client goals and values, offering practical recommendations to support their preferred way of living at home. Follow-up sessions with our Social Worker or Allied Health Assistant may be recommended to further support care planning and implementation.

Social work assessment may benefit clients greatly who are showing:

Signs of emotional distress and social isolation
Family conflict, carer stress or neglect
Difficulty managing the home or finances
Complex psychosocial barriers to care engagement

Initial Social Worker Assessment: Initial consultation & report at clients home [$406.00] by our Allied Health Professional team.

Please note for your reference:

Ongoing Social Worker Service Rates:

Social Worker:Sessions carried out at the clients home or via telehealth [$202.95]

Allied Health Assistant: Sessions carried out at the clients home or via telehealth [$111.65] the Allied Health Assistants complete their tasks inline with the Social Workers initial assessment and care plan.

Nail Care Therapy

Nail Care Therapy: Initial consultation, assessment & service at clients home [$217.80]

Nail Care Therapy: NDIS Therapy Assistant 15_053_0128_1_3. Initial consultation, assessment & service at clients home [$217.80]

Please click here : To acknowledge that this service is not a Podiatry service. Our therapists will provide recommendations to a GP, RN or Podiatrist if there are any contraindications identified and are unable continue service. *

Follow on Nail Care Sessions. *

Yes - The client has adequate funding for follow-up sessions. Following the initial assessment and after the client has given consent for ongoing. Summit Health may schedule once a month sessions (11 sessions after the initial) - Total $1228.15 (individual sessions are $111.65). After 11 sessions funding request will be sent again.No - client does not have adequate funding for follow-up sessions. Please discuss with Care Coordinator.

NDIS subsequent *

Yes - The client has adequate funding for follow-up sessions. Following the initial assessment and after the client has given consent for ongoing. Summit Health may schedule once a month sessions (11 sessions after the initial) - Total $998.25 (individual sessions are $90.75). After 11 sessions funding request will be sent again.No - client does not have adequate funding for follow-up sessions. Please discuss with Care Coordinator.

Group Exercise Programs

Group Exercise Program

Falls Prevention ProgramTelehealth Wellness Live Group Exercise program

Live Telehealth Group Exercise Program: Participants engage in 45-minute sessions focusing on strength, cardiovascular health, balance, and coordination, led by an exercise professional via video or phone, with support from provided handouts and equipment. Exercises are offered at varying difficulty levels to maximize benefits. Ideal for clients with lower-level funding, the 8-week program offers unlimited participation with live sessions on Monday, Wednesday, and Friday at 9:30 AM.

8 Week Block - Live Group Exercise Program : Mon, Wed, Fri 9:30 am sessions, workbooklet, equipment, wellbeing emails [$396 inc GST]

The 12-week Falls Prevention Program aims to reduce fall risks, increase awareness, and improve confidence in a supportive environment. Conducted in person at our Deakin studio space, it provides all necessary equipment and materials to promote safety and independence. The program is paid in full and the first session the client attends kicks off their 12 weeks of the program.

This client has adequate funds to participate in the 12-week falls prevention program - total cost = $360.00

Participants email address for course correspondance

Appointment booking details

Preferred time of day

MorningMid-dayAfternoon

Translator required?

Yes - a next of kin is able to translate or Care Manager will arrange translator (Please provide no. of the NOK or Translator)No

Note: Summit health Solutions does not provide translator at the moment.

Is this client Aboriginal or Torres Strait Islander origin?

NoYes, Aboriginal Yes, Torres Strait Islander

What language is required

Completion of referral form

This client will be paying for their services and is aware of the costs. I have included the clients email to whom the invoices can be sent to. *

Privately paying clients email address *

Name of Care Manager *

Signature *

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Thank you for sending us this referral.

We look forward to working with your client soon.