NDIS Client Referral

Welcome to Levaro!

Thank you for considering Levaro as your service provider, we want you and your clients to feel safe, welcome, and respected.

Levaro takes your privacy seriously - you can visit our privacy policy for more information.

If you have any questions when making this referral, you can call our office : (02) 4001 0525

Referral Date *

Are you the: *

ClientReferrer

Is the referrer also to be listed as an alternative contact? *

YesNo

Is this a referral for an existing Levaro client? *

YesNo

If you're unsure OR this referral is for an existing client using a different funding organisation, select 'No'

Client First Name *

Client Surname *

Referrer Details (Person Making the Referral)

First Name *

Last Name *

Agency *

Role *

Email Address *

Phone Number *

I have obtained consent from the client to make this referral and provide Levaro with the clients personal and medical details *

YesNo

Is the referrer approved to act as Client Representative and sign Service Agreements?

YesNo

Client Details

First Name *

Surname *

Preferred NameHave a different name you prefer? If so, we'll try to use it when possible.

Date of Birth *

Gender

MaleFemaleFurther Gender Information

Gender Information (Optional)

Phone NumberPlease ensure at least one contact method is provided.

Email Address

Street Address *

City *

State *

Postcode *

Is there an alternate contact? *

YesNo

Is this contact to be the primary point of contact?

YesNo

Is this alternate contact approved to act as the Client Representative and sign Service Agreements?

YesNo

Alternate Contact Details

First Name *

Surname *

Relationship *

EmailPlease ensure at least one contact method is provided.

Phone Number

Reason For Referral

Referred for: *

Occupational TherapyPhysiotherapySpeech PathologyExercise Physiology

Occupational Therapy Hours *If TBC please enter '0'

Occupational Therapy Budget

Physiotherapy Hours *If TBC please enter '0'

Physiotherapy Budget

Speech Pathology Hours *If TBC please enter '0'

Speech Pathology Budget

Exercise Physiology Hours *If TBC please enter '0'

Exercise Physiology Budget

Total Budget

Medical Diagnosis / Information *

Support needed / reason for referral *

File Upload (Please attach a copy of the current NDIS plan if possible)

Browse

Frequency of supports *

WeeklyFortnightlyMonthlyAs scheduled

Location of supports *

Client HomeClinicTelehealthAs scheduled

NDIS Details

Plan Type *

Plan Managed Self Managed Agency Managed

NDIS Participant Number *

Please advise where the funding should be claimed from *

Capacity Building – Improved Daily Living – Therapy SupportsCapacity Building – Improved Health and WellbeingCore – Assistance with Daily Life - Disability-Related Health Supports

Plan Start Date *

Plan End Date *

If our service dates are to be different from particpant's plan dates, please specify:

Service Start Date

Service End Date

Billing Email

Client Goals (As stated in the NDIS plan)

Plan Manager Name *

Plan Manager Accounts Email *

Plan Manager Postal Address

Is the participant's plan attached to this referral? *

YesNo

Risk Assessment

Thank you for addressing the risk assessment questions below. This ensures the safety of all parties.

Property Access

Is the client able to open the door? *

YesNo

Is the home the therapist will be visiting the same as the clients address given above? *

YesNo

Any time restrictions on visiting hours? *

Yes No

Does the client speak English? *

YesNo

Are there any other occupants or visitors likely to be home during the visit? *

YesNo

Are there firearms in the house? *

Yes No

Is there a known substance abuse amongst occupants or visitors? *

YesNo

Please provide more details or any other risk / safety factors you are aware of? *

By ticking this box, you are agreeing to provide true and accurate information. *

Health

Does the Client have or has recently been in contact with a positive COVID-19 case or do they have any infectious diseases? (e.g. gastro, flu etc.) *

YesNo

Are you aware of any risks within the home (e.g. pets or animals, bad phone coverage, flood risks)?  *

Yes No

Does the client have a behaviour support plan in place? ( Please provide a copy ) *

Yes No

Is anyone at the clients address known to have behavioural concerns? *

YesNo

Provide details *

File upload

Browse

Clinical Manager Approval

Referral details confirmed with referrer *

YesNoChanges Required, workflow back to referrerReferral not accepted

Allocated Occupational Therapist: *

OT Hours Allocated *

Physiotherapist Allocated: *

Physiotherapist Hours Allocated *

Speech Pathologist Allocated: *

Speech Pathology Hours Allocated: *

Exercise Physiologist Allocated: *

Exercise Physiology Hours Allocated: *

Total Hours Allocated

Time frame for Therapist to contact Client (to go in iinsight task) *Eg: ASAP, 5 days, 2-3 weeks or 3+ weeks

Any notes for Admin?

Referral Setup

New client entered into iinsight *

New client entered into Xero if Self Managed or check contact details are up to date (with potential new client information) *

Please upload any documents attached to this referral (if any) to the client file *

If this Client is changing Funds Management, Please ensure correct Client tab - Funding Type, Case tab - Service Contract, Contacts - Bill To BEFORE making Funding Plans (if no change, check these match the info anyway) *

Draft funding plan/s set up or changed in iinsight - using template Total Sum - time based - including tracking category
(If an interim is requested please make Active and still use Total Sum - TIME BASED - 1.3h)
Ensure old plans are made inactive - then switch this new plan to DRAFT *

OT item number: 15_617_0128_1_3

Speech item number: 15_622_0128_1_3

Physio item number: 15_055_0128_1_3

EP item number: 15_200_0128_1_3

Please only select
OT item number: 01_661_0128_1_3

Please only select
Speech item number: 01_665_0128_1_3

Please only select
Physio item number: 01_721_0128_1_3

There is no CORE funding for EP

Funding plan/s set up in iinsight - using template Total Sum - time based - including tracking category

Tasks created for each Therapist in client's iinsight file with the associated information as per screenshot below *

Specified time frame for task

Priority of tasks are:

Low - 3+ weeks

Medium - 2/3 weeks

High - ASAP/1 week

Please select Status = New Referral New Client

Please select Status = New Referral Exisiting Client

Please add Clent as Contact to Xero using Name and Email address, then scroll right down to the bottom, assign the Invoice Theme to "NDIS New" (or Standard if Medicare/Private) and set the Due Date as 7 days after invoice date.

All Therapists involved in care updated to "modify" in iinsight in Case >Assigned to *

Claim plan due date updated in Case >Claim Plan Due Date *

Service Booking complete in PRODA Portal at CATEGORY LEVEL ONLY *

Support Category - CB Daily

Support Category - Daily Activities

Link to the NDIS Service Agreement Form

If there is truley no email address for the Client/Client Rep - please check Hardcopy sign on the SA

Service Agreement sent for execution *

Add CASE ALERT on Iinsight in Settings with link to SA for signing *

Admin Team Member completing this form *

Save and Complete Later