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Private Allied Health Referral Form

If you have any issues with this referral form or require more support, please contact us at or by calling 1800 000 677.

Participant Information

Interpreter required
Communication preferences or requirements
Access requirements

Advocate and Guardian Information

Does the participant have

Referrer Information

Services Required


Diagnosis and Background


Please provide a copy of any relevant previous allied health and medical reports, if available.

Click or drag files to this area to upload. You can upload up to 25 files.
Accepted file types: .xlxs, .jpg, .jpeg, .doc, .docx, .pdf, .png

Risks and Safety

Are there any court orders or legal proceedings applicable, e.g. child custody?
Has the participant ever been physically aggressive towards allied health, medical or support staff?
Has the participant been incarcerated in a prison, juvenile detention centre or spent time in a forensic hospital for a violent or sexual offence?
Is the participant currently engaging in alcohol or drug use?
Are there any known risks for visiting the participant in their own home?

Initial Assessment

Location of initial appointment
Are there any preferences for a consultant?
Appointment reminders

Service Agreement

Who will sign the service agreement

Payment Method

Who does ORS invoice? (please select all that apply)

Further Information


Please note:  We endeavour to process referrals within 2 business days and will call you to schedule an appointment. If we are unable to make contact by telephone, we will schedule the appointment and email this to the contacts provided in this referral form. This email will confirm the appointment date and time, and any additional documentation or information required prior to the appointment. We would appreciate you looking out for this email and letting us know as early as possible if it needs to be rescheduled.

If your referral is urgent, please call us on 1800 000 677.