What's Inside
A comprehensive referral and intake form designed specifically for Occupational Therapy services in the Support at Home program - helping you collect the right information from the start, reduce referral delays, and streamline your intake process.
 
Too often, referrals arrive with missing clinical information, unclear funding details, or incomplete goals, leading to unnecessary follow-up and delayed service delivery. This template provides a structured referral pathway that captures everything you need to triage, allocate and commence OT services with confidence.
 
Built specifically for the Support at Home program, with funding, service and clinical prompts relevant to contemporary community aged care practice.
 
Template - Support at Home OT Referral & Intake Form
 
A structured referral document that gathers the clinical, funding and administrative information required to commence Occupational Therapy services efficiently.
Participant and provider details – captures participant demographics, contact information, case manager details, invoice contacts and referring organisation information.
Support at Home funding information – documents funding type, participant classification, budget category, package details and approved referral budget to support accurate service planning.
Current services snapshot – records existing clinical, independence and everyday living supports to minimise duplication and identify opportunities for interdisciplinary care.
Comprehensive OT service request checklist – includes common community OT services such as initial assessments, assistive technology, home modifications, falls prevention, cognitive assessment, dementia assessment, seating, low vision and reablement.
Clinical history and risk screening – prompts for diagnoses, cognition, falls history, mobility, equipment, social supports and other relevant information to support safe and effective triage.
Goal-focused referral planning – captures participant goals, provider goals and key functional concerns to ensure services remain person-centred from the outset.
Consent and governance documentation – includes referral declarations, consent statements and provider-use sections to support consistent documentation and record keeping.
 
Use it as:
a referral form for registered providers · an intake document for private practice or community OT services · a triage tool for allocating referrals · a consistent information-gathering template for administrative staff · or customise it with your own branding and organisational workflows.
 
Who it's for
Occupational therapists and community aged care providers delivering services under Support at Home, Home Care Packages or CHSP who want a professional, comprehensive referral process that reduces administration and improves referral quality.
 
Format
Print-ready, fully editable Word document · Customisable with your organisation's branding · Designed specifically for Occupational Therapy services in community aged care.