Neuropsychological & Psychological Assessment & Rehabilitation Services

REFERRAL INTAKE FORM

Thank you for completing our referral form. The information you provide helps ensure that your referral is processed accurately and in a timely manner. Please make sure to include all required information specific to our services and relevant to your referral needs. You can attach any supporting documents using the upload tool at the end of this form.

If you have any questions, please call 9043 9033 or email referrals@memory-matters.com.au. A member of our friendly team will be happy to assist you.

Referrer Details

If this is a self-referral, you are not required to complete this section. Please complete participant details below.

Referral Date

Name

Organisation

Best Contact Number

Email address

I have obtained consent from the participant to make this referral and provide Memory Matters with the participant's personal and medical details.

Participant Details

Title

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

Preferred Pronouns

Aboriginal / Torres Strait Islander

YesNo

Country of Birth

Interpreter Required?

YesNo

Main Language Spoken

Best Contact Number *

Email Address

Preferred Method of Contact *

Phone CallTextEmail

Address *

City / Suburb *

Postcode

Please specify accomodation type

Facility Manager Name

Facility Manager Contact Number

Facility Manager Name

Facility Manager Contact Number

Primary Contact

Who is the Primary Contact? *

ParticipantParticipant RepresentativeBoth

For general correspondence and scheduling of appointments

Who will be signing the Consent Forms?

ParticipantParticipant RepresentativeOther

A Participant Representative is a substitute decision-maker authorised to consent on behalf of an individual

Name

Relationship to Participant

Best Contact Number

Email Address

Participant Representative

Please specify relationship

Name

Agency

Best Contact Number

Email Address

Postal Address

Emergency Contact

Is the Emergency Contact the same as the Primary Contact?

YesNo

Name

Relationship to Participant

Best Contact Number

Email Address

Funding Body

National Disability Insurance Scheme

Schedule of Supports

Neuropsychology services provided by Memory Matters are funded under the following support categories:

Please select support item/s

Capacity Building - Improved Daily Living - Therapy Supports - Psychologist (15_054_0128_1_3)Core - Assistance with Daily Life - Therapy Supports - Psychologist (01_701_0128_1_3)

Please note: Memory Matters can provide Behaviour Support Intervention but is not registered to provide services under the category of Improved Relationships.

NDIS Plan Number

Available Funds for Neuropsychology

NDIS Plan Start Date

NDIS Plan Finish Date

Support Coordinator Name

Support Coordinator Agency

Support Coordinator Email Address

Support Coordinator Contact Number

PLAN MANAGER

Plan ManagedSelf Managed

Plan Manager Name or Agency

Plan Manager Email Address for Invoices

Who will be settling the account?

ParticipantParticipant Representative

Additional information relevant to the plan

I have attached a copy of the current NDIS plan (or relevant excerpts of the plan)

Documents can be attached using the upload files tool at the end of the form

Transport Accident Commission (TAC)

TAC Claim Number

Support Coordinator Name

Support Coordinator Contact Number

Support Coordinator Email Address

Documents can be attached using the upload files tool at the end of the form

Community Integration Program (CIP)

CIP Claim Number

CIP Support Coordinator Name

CIP Support Coordinator Contact Number

CIP Support Coordinator Email Address

WorkSafe

WorkSafe Claim Number

WorkSafe Agency

Claims Manager Name

Claims Manager Contact Number

Claims Manager Email Address

Medicare

Medicare Name

Medicare Card No.

Medicare Card Reference No.

Medicare Card Expiry(mm/yyyy)

I have attached a copy of my Mental Health Care Plan

Documents can be attached using the upload files tool at the end of the form

Private Health Insurance

Health Insurance Provider

Health Insurance Number

Health Insurance Contact Number

Expiry Date(mm/yyyy)

DVA

DVA Number

DVA Card No.

DVA Card Expiry(mm/yyyy)

Private

Who will be settling the account?

Best Contact Number

Email Address for Invoices

Referral Information

Services

Memory Matters is a statewide outreach service. We offer community-based assessment, rehabilitation and support services to children and adults of all ages, as well as their families and support teams. If you would like more information about our services below, please visit our website www.memory-matters.com.au.

Please select the services you require *

Neuropsychological AssessmentNeuropsychological Intervention Psychological Intervention Positive Behaviour Support

Cognitive RehabilitationReturn to Work Assessment & CounsellingEducational AssessmentGroup Program

Service Location

Preferred location for appointments

Memory Matters Office - MitchamHome VisitTelehealth

Reason for Referral

Please describe the primary reasons for referral *

Relevant background information

Please list all known diagnoses

Please describe any known cognitive problems

Please describe any communication issues

Please list any behaviours of concern

Additional Information

Please list any known risks associated with seeing this participant including home visits *

Legal Issues

Are there any of the following in place?

VCAT appointed AdministratorVCAT appointed GuardianActive Power of Attorney

Representative Name

Representative Best Contact Number

Health Providers

Please include name, contact number and email address in the fields below.

General Practitioner

Occupational Therapist

Physiotherapist

Speech Therapist

Exercise Physiologist

Other Therapist

Upload Files

Please upload supporting documents here

Browse

Reports, previous assessments, health plans, medical information, discharge summaries, funding provider documents

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