Evolve Referral Form

Date *

Client Details

First Name *

Last Name *

Date of Birth *

Known As

Phone Number *

Email

Address *

Please provide any additional information regarding access to the property

Diagnosis of Client requiring Services *

Client Representative

First Name

Last Name

Relationship to Client

Contact Phone Number

Contact Email

Referrer Details

First Name

Last Name

Organisation

Referrer's relationship to Client

Other relationship

Referrer Phone

Referrer Email *Please enter n/a if self referred

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Funding Information

If other please explain *

NDIS Number *

Agency Management: *

Plan Start Date *

Plan End Date *

Plan Manager Company *

Invoicing Email *

We will claim these invoices on PRODA Portal

The Client/Client's Representative is aware they will need to endorse Evolve as a MyProvider in the PACE system
Click here for more information about PACE

Estimated Budget Allocated for Requested Services - $ or hours

Category for NDIS funding *

If CORE Supports are to be used - please provide evidence of approval *

If Self Managed, the Client/Client's Representative is aware they will need to endorse Evolve as a MyProvider in the PACE system
Click here for more information about PACE

Send Service Agreement to *

Contact for arranging appointments *

If the Client consents, please upload a copy of the NDIS Plan if able

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Any other reports or documents that may assist with Services for the Client

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Please provide an ideal time frame *

Risk Factors

Risk Decision *

Green (no known risks)Orange (some risks, please provide description)Red (requires comprehensive handover and 2 staff in attendance at any session, more details below)Blue (environment risk, please explain)

These risks may entail any persons present at the appointments or location, or involved in this Client's care

I will liaise with the Therapist to provide a support person for all visits for this Client *

Services

Is there a Secondary Therapy Service Required? ** YES - 2 or more Services (eg: OT and Physio) * NO - 1 Service only

Please describe the situation

Primary Service

Select required primary service *

Occupational TherapyPhysiotherapyPsychologyExercise Physiology

Please also select your Secondary service below

Primary Diagnosis as recognised by NDIS/Specialists *

Relevant Medical History *

Requested Supports or Reports *

Please provide any relevant documents or reports

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Review by Directors: Primary Service

This Client is suitable for services *

YesNoNeed further info

Please describe what further info is required from referrer *

If no provide reasoning: *

This Client suitable to release Report before payment (e.g. known PM)

Suitable appointment location options *

HomeOther as needed by Client

Any further information for Therapist

Grace Curtis, Therapy Assistant, may also work with this Client.

Staff Member Allocated *

Staff Member Email *

Ideal time frame for providing services *

Review by Therapist: Primary Service

I accept this referral: *

Yes NoRequires Further DiscussionAdmin Reset

Please do not select Admin Reset unless you are Admin

The Directors are happy for any Reports for this Client to be sent with payment after
(Known PM etc)

The Directors have asked for payment PRIOR to release of any Reports for this Client

If no, please provide reasoning: *

Grace Curtis, Therapy Assistant, will also be assigned to this Client.

I am aware that the ideal time frame for providing services is:

Date/Time of proposed non-confirmed initial appointment *

Location of appointment

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalisation: Primary Service

Next Steps

Admin setup case file in sploseAdmin send SA - please choose from list

Change in Current Therapist?The SA will be setup with the Client's current Therapist, unless stated here to change and to whom

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

NDIS Funding Category

Please include Grace's TA2 hours

Any other notes for Admin?

Secondary Service

Select Required Secondary Service *

Occupational TherapyPhysiotherapyPsychologyExercise Physiology

Secondary Diagnosis *

Relevant Medical History *

Requested Supports or Reports *

Review by Directors: Secondary Service

This Client is suitable for services *

YesNoIncorrect choice by Ref

Any further information for Therapist

Staff Member Allocated *

Staff Member Email *

Ideal time frame for providing services *

Review by Therapist: Secondary Service

I accept this referral: *

Yes NoRequires Further DiscussionAdmin Reset

Please do not select Admin Reset unless you are Admin

The Directors are happy for any Reports for this Client to be sent with payment after
(Known PM etc)

The Directors have asked for payment PRIOR to release of any Reports for this Client

If no, please provide reasoning: *

I am aware that the ideal time frame for providing services is:

Date/Time of proposed non-confirmed initial appointment *

Location of appointment

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalisation: Secondary Service

Next Steps

Admin setup case file in sploseAdmin send SA - please choose from list

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

NDIS Funding Category

Any other notes for Admin?

Therapist Review: Primary Service

I accept this referral: *

Yes Requires Further Discussion

I am aware that the ideal time frame for providing services is:

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalisation Primary

Next Steps

Admin setup case file in sploseAdmin send SA - please choose from list

Further discussion is required, we will attend this with the Therapist - please await Service Agreement instructions

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Therapist Review: Secondary Service

I accept this referral:

Yes Requires Further Discussion

I am aware that the ideal time frame for providing services is:

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalisation Secondary Service

Next Steps

Admin setup case file in SploseAdmin send SA - please choose from list

Further Secondary Discussion

Further discussion is required, we will attend this with the Therapist - please await Service Agreement instructions

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Admin Actions

First Steps

Setup file in Splose;Reason for Referral added to 'Other Details' during setup;Client Representative and Referrer added to 'Other Details' and as ContactsAttached files uploaded (create a Referral Information folder if required) including Ref Form that comes through when completed;Any extra emails re this referral in admin@ added to Correspondence Folder (create if needed)

This Client is SELF MANAGED - please assign the Bill-To as their email address

This Client is PLAN MANAGED - please assign the Bill-To as per info in form

This Client is AGENCY MANAGED - please assign the Bill-To as NDIA with email of "Bill to Portal"

Please add the Grace Tag also

Therapist 1

Therapist 2

Please add this appointment to Splose for Therapist 1

Please add this appointment to Splose for Therapist 2

Report Tag selected

Ongoing Therapy Tag Selected

Please await further instructions from the Directors directly in regards to the Services required for this Client

Please do not attend Case Plan setup

Please review requirement for Case/SA as this has gone through multiple Therapist reviews

Case budget setup in Splose.
- Please title Surname dd.mm.yy - dd.mm.yy (if more than one Service name as eg: Surname OT dd.mm.yy etc)
- Type: Budget
- Case Alert: 70% and 4 weeks out to Assigned Therapist
- for 1.5hours and note the full hours to be updated when SSA returned in Notes section of case

Service Booking created on PRODA Portal
(CB Daily = CB Daily, CORE = Daily Activities)

ALL Therapists involved in care have "End of Plan" Support Activities created and assigned to them *

Second Steps

Risk category tag added (if red or orange) and notes updated in Alerts;NDIS Plan dates & NDIS No. added into Splose Date fields

Please choose required:

NDIS Service Agreement SnapForm click here

Private Service Agreement SnapForm click here

NDIS Funding Category

Please add "Person to liaise with for appointment" an associated contact and select appt

SA sent

Sent Service Agreement for signing

Please add tag Unsigned SA in splose - include link to SA in Alerts

Send to Client

Send to Rep

Send to Referrer

Send to Therapist

Client created and updated in Asana

Team member completing this Form *

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