Workplace Rehabilitation:

National Disability Insurance Scheme (NDIS):

Psychological Services:

Workplace Rehabilitation

Claim Number

Workers Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (work)

Interpreter required

Yes
No

Language

Reason for referral

Nature of injury

Date of injury/accident

Is the injured worker presently working

Part-time
Full-time
Not working

Date they ceased work

Occupation

Average weekly earnings

Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Contact name

Treating doctor

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Referred by

Employer
Doctor
Insurer
Self

Name of referrer

Phone

Referrer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Approved costs

In which state has this Workers’ Compensation Claim been made*

ACT
NSW

How did you hear about ORS Group?

Upload Files

Drop files here or

please attach any supporting information

National Disability Insurance Scheme (NDIS) Referral Form

I'm referring*

Myself to ORS
Someone else to ORS

Does the customer have an advocate/guardian?*

Yes
No

Residential information:*

Private Residence
Group Home
Hospital
Aged Care Facility

NDIS Plan Information

NDIS number*

NDIS Plan - start date*

NDIS Plan - end date*

Customer information

Customer full name*

Date of Birth*

Phone (home)

Phone (mobile)

Email

Private Residence

Address

Street Address City State / Province / Region ZIP / Postal Code

Group Home

Address

Street Address City State / Province / Region ZIP / Postal Code

Hospital

Address

Street Address City State / Province / Region ZIP / Postal Code

Aged Care Facility

Address

Street Address City State / Province / Region ZIP / Postal Code

Are there any access/reasonable adjustment requirements?

Yes
No

Please specify access/reasonable adjustment requirements

Customer origin

Aboriginal/Torres Strait Islander
Culturally and Linguistically Diverse
N/A

Communication preference

Telephone
Email
Face to face
Mail

Advocate name

Email

Phone

Advocate/Guardian address

Street Address City State / Province / Region ZIP / Postal Code

Who should ORS contact to book appointments?

Customer
Advocate/Guardian
Referrer

Does the customer have a preferred appointment day/time?

Yes
No - Any time/day is suitable

Specify preferred day/s time (Monday to Friday between 9am and 5pm)

Who will sign the Service Agreement?

Customer
Advocate/Guardian
Referrer

Has the customer:*

got a criminal history
spent time in prison or a forensic hospital
shown aggressive or challenging behaviour
N/A

Please provide details:

NDIS support area/s being requested*

To select multiple NDIS support categories hold (Ctrl) and click

Details of support required

E.g: Behaviour Assessment, Functional Capcity, Assistive Technology, Employment Assistance etc.

How are finding and keeping a job funds managed?

NDIA
Self-Managed
Plan Managed

How are school leaver employment support funds managed?

NDIA
Self-Managed
Plan Managed

How are improved health and wellbeing funds managed?

NDIA
Self-Managed
Plan Managed

How are improved relationships managed?

NDIA
Self-Managed
Plan Managed

Are there any restrictive practices in place?

Yes
No
Currently requesting
N/A

How are improved learning funds managed?

NDIA
Self-Managed
Plan Managed

How are improved daily living funds managed?

NDIA
Self-Managed
Plan Managed

Plan Manager details

Organisation

Name

First Last

Phone

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

Please list relevant disability, health and medical conditions

Are you able to provide ORS with any reports or assessments which may assist in servicing our customer?

Yes
No

Upload Files

Drop files here or

please attach any supporting information

Referrer details

Are referrer details same as advocate/guardian?

Yes
No

Organisation (if applicable)

Name*

First Last

Phone*

Email*

Address

Street Address City State / Province / Region ZIP / Postal Code

How did you hear about ORS Group?

Enquiry

Name*

First Last

Email*

Contact number

Please include area code

How can we help you?

How did you hear about ORS Group?

Private Allied Health Services

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Assessment Request:

Psychological Counselling
Vocational Assessment Report
Worksite / Ergonomic Assessment
IQ Assessment / Moderate Intellectual Loading Assessment
Psychological Assessment
Occupational Therapy Assessment

Referring Company:

Staff Member Name:

Referrer Address:

Referrer Phone:

Referrer Email:

Are the Billing Details different to the above?

Yes
No

please complete the below:

Billing Company:

Staff Member Name:

Billing Address:

Billing Phone:

Billing Email:

Is an Interpreter Required?

Yes
No

Language

Job Barriers / Medical Information / Reason for Referral:

Services that work

Referral Form

Step 1 of 2

Workplace Rehabilitation:

National Disability Insurance Scheme (NDIS):

Psychological Services: