Refer as a Family Member or Self referral

Referral Form

We have an online referral form for your convenience. It's fairly extensive so if you find it overwhelming or difficult to complete please just enter the required fields (marked with an asterisk*) and remember to press the orange submission button at the bottom of the form. The more comprehensive the information we receive, the faster we can assess the situation and make arrangements.

If you are referring as a Care Provider or Health Provider, please do not complete this form. Instead, proceed to the appropriate referral form here.

As soon as we have assessed this information, our Practice Manager, will be in touch to progress the referral. 

Need help? Call the office on

 0420 107 002 or email referrals@equippedtofunction.com.au


Primary Email Address for Contact Purposes*
Client's Name* (client is who will be receiving OT services)
Client's Address*


Client's DOB*
Client's Phone Number* 
Next of Kin Name
Next of Kin Email
Is the next of kin the primacy contact?
Next of Kin Relationship
Next of Kin Phone Number 
Reason for Referral
0 of 600
Previous Medical History / Current Diagnosis
0 of 350
Mobility/Transfers Information
0 of 350
Are there any support services in place?
0 of 350

CARE PROVISION AND FUNDING

Is a Home Care Package currently in place?
CANCELLATION POLICY
Equipped To Function requires one business days’ notice to change or cancel a client's appointment.  We understand that there are sometimes unavoidable situations where an appointment will need to be rescheduled or cancelled however a late cancellation fee may be applied if less than one business day is provided.  A cancellation/reschedule fee equal to one hours' treatment time will apply for a standard OT referral and two hours' treatment time in the case of a home modifications assessment.  One hour will be charged or up to two in the case of a home modifications assessment. Reschedule or cancellation notifications can be submitted via phone to the Practice: 0466 632 166 or by email: referrals@equippedtofunction.com.au. Our practice hours are Monday-Friday, 8am-4pm. 
 SUBMIT REFFERAL