CLINICAL SERVICE REFERRAL FORM

1. Referrer Details

Referrer's Full Name *

Referrer's Email Address *

Referrer's Phone Number

Role *

Organisation Name

How do you want to be included in the Clients Care?

Attend sessions in personAttend Sessions via telehealthCommunicate via phone or email

Which appointments would you attend? (Select all that apply) *

AssessmentScan / Cast AppointmentFitting AppointmentReview Appointments

Preferred Location

2. Client Details

Client First Name *

Client Last Name *

Client Date of Birth *

Sex

MaleFemaleOther

Is there an admin person you'd like to have complete administrative details for this referral? eg. Client Service Consultant *

YesNo

If yes; the nominated admin person will be contacted using the provided email address to completed the administrative components of this form.

Admin Support Person's Full Name *

Admin Support Person's Email *

2.1 Administrative Details

Client Address

Street AddressStreet address line 2

Suburb

State

Postcode

Does the client have a contact representative? *

YesNo

e.g. Parent, Carer, Guardian or other authorised person as primary contact

Client Representative Full Name *

Relationship to Client

Contact Email

Contact Phone Number

Preferred Contact Method

Does the Client have NDIS? *

YesNoUnsure

Client NDIS Number *

NDIS Funding Type *

NDIS Plan Start Date

NDIS Plan Date Due for Review

Is there 3 hours capacity building budget available for Initial Assessment and report writing?

YesNoUnsure

Does the client have an Assistive Technoloy Budget for Orthotics? *

YesNoUnsure

Additional Funding Details

Does the client have a contact representative? *

YesNo

e.g. Parent, Carer, Guardian or other authorised person as primary contact

Client Representative Full Name *

Relationship to Client

Contact Email

Contact Phone Number

Preferred Contact Method

Does the Client have NDIS? *

YesNoUnsure

Client NDIS Number

NDIS Funding Type *

NDIS Plan Start Date

NDIS Plan Date Due for Review

Additional Funding Details

3. Clinical Information

Please provide as much clinical information as possible to assists with orthotic assessment and prescription.

Which best describes your familiarity with this client? *

New or unfamiliar client to meKnown clientKnown client – I have an orthotic approach in mind

This helps us understand your familiarity with the client and the level of clinical detail available.

Proposed Orthotic Device or Approach

3.1 Diagnosis

Intervention Side

LeftRightBilateralUnsure

3.2 Orthosis History

Orthosis Use

Currently Uses an OrthosisPreviously Used an Orthosis (not currently)Has Never Used an OrthosisUnsure

Current Orthotic Device(s)

Previous Orthotic Device(s)

3.3 Goals

Currant Client Goals

Walk longer distancesReduce fatigue during walking or standingIncrease participation in sport or recreationImprove comfort when standing or walkingImprove comfort when seated in wheelchair Improve participation at school / workImprove independence with mobilityReduce pain Other (please specify)

3.4 Function

Gross Motor Function Classification System (GMFCS) Level

Functional Ambulation Category (FAC) *If unsure select the closest description.

Biomechanical Issues

Gait

Toe WalkingPoor Foot Clearance During SwingReduced Ankle Dorsiflexion / Limited Tibial Progression

Foot Alignment

Pronation / Midfoot CollapseSupination

General

Asymmetrical Weight BearingLeg Length Discrepancy

Leg length Difference (if known)

Additional Clinical Details (Optional)

3.5 Measurements

Are there any concerns regarding lower limb muscle tightness, contracture, or risk of contracture? *

YesNoUnsure

Where is this concern present? (select all that apply) *

AnkleKneeHip

Affected Side *

LeftRightBilateralunsure

Ankle Measurements

RIGHT

LEFT

Dorsiflexion (with Knee Flexion)

Dorsiflexion (with Knee Extension)

Knee Measurements

RIGHT

LEFT

Extension

Flexion

Hip Measurements

RIGHT

LEFT

Extension

Flexion

Abduction (with Knee Extesion)

Abduction (with Knee Extension)

Abduction (with Knee Flexion)

External Rotation

Internal Rotation

Additional Measurements (if applicable)

Are there concerns regarding muscle tone? (spasticity, dystonia, hypertonia ect.) *

YesNoUnsure

Muscle Tone/Spasticity Details (if assessed)

3.5 Medical History

Relevant Medical History

Relevant Surgical History

4. Final Details

Is this referral urgent? *

YesNo

Notes on Urgency *Please explain why the referral is urgent and the preferred timeframe for assessment or fitting.

Is serial casting planned or currently underway? *

YesNoUnsure

PLEASE NOTE:

Standard turnaround from casting to fitting is 4 weeks; please ensure the client is in suitable bracing to maintain ranges during that time.
Manufacture can be expedited to 3 weeks with a rush fee. Please advise in this client form if this would be preferable. It will be subject to funding availability and client consent.
If known, please provide ideal AFO casting date. This should be as soon as you expect ranges to stabilise.
We will need to assess/review the client before serial casting begins in order to prescribe and issue the deposit invoice
Allow at least 3 weeks from assessment/review for deposit invoice to be arranged and paid before we can cast for AFO, and factor in time for us to book in an assessment/review (if the clinic is full, next available appointment can be a few weeks away).
If serial casting has yet to be scheduled, please provide intended estimated timeframe so we can coordinate
If you need to discuss serial casting plans with orthotist or be at a joint review, let us know and we will arrange accordingly

Serial Casting Details *

Additional Notes (Optional)

Upload Supporting Documents (Optional)

Browse

e.g. gait analysis, limb photos, orthosis photos, clinical reports