Old Forms – Greater Health

Support at Home / Home Care Package Referrals

Submit a 2-3min referral and we’ll coordinate the next steps with your team.

Consent *

I have gained consent from the participant to share this information for the referral request

Participant Details

Full Name *

Date of Birth

Address

Residence Type (optional)

Private Home
Retirement Village
Residential aged-care facility

Primary Contact details - Who should we contact (client/carer/nominee)

Name (optional)

Phone

Relationship

Mobile

What is their preferred method of communication (optional)

Emergency Contact Details (optional)

Name:

Relationship

Phone

Health Background

Primary Health Condition(s) / Diagnoes

Any Medications (if known)

Allergies (if known)

Mobility aids (optional)

Support at Home / Home Care Package Details

My Aged Care ID Number

Plan Start Date (optional)

End/Review Date (optional)

Funding

Funding Details

Self-managed
Provider-managed

Funding Level - Home Care Package (option 1)

Level 1
Level 2
Level 3
Level 4

Funding Level - Support at Home (option 2)

Classification 1
Classification 2
Classification 3
Classification 4
Classification 5
Classification 6
Classification 7
Classification 8

Invoicing Preferences - who can we send the invoices to?

Name

Case Manager details (if applicable) (optional)

Name

Phone (optional)

Goals

Client Goals - may be found on their Support at Home / Home Care Package plan (what would they like to achieve with their exercise physiology program?) (optional)

Participant Goals - may be found on their NDIS plan (what would you like to achieve with your exercise physiology program?) (optional) (copy) (copy)

Participant Goals - may be found on their NDIS plan (what would you like to achieve with your exercise physiology program?) (optional) (copy)

Where would your client prefer sessions? (tick all that apply)

Session Preferences

Home visits
Gym
Hydrotherapy
Telehealth (video or phone)
Private Exercise Studio
No preference or unsure

Preferred session length (follow up sessions)

Preferred (follow-up) Session Length

60-min
45-min
30-min

How Often

Frequency

Weekly
Fortnightly
Monthly

Anything we should know for safety? Tick all that apply

Safety (standardised)

Seizures
Communication support required
Falls risk
Manual handling required

Upload any care plan or other relevant information applicable to referral [folder]

Upload any care plan or other relevant information applicable to referral) [folder]

Upload any care plan or other relevant information applicable to referral) You can upload up to 1 files.

Signature

Digital or typed are accepted:

Upload your signature here. You can upload up to 1 files.

Name

Role

Date

Got questions?

Contact the Lead Accredited Exercise Physiologist directly
E: caroline@greaterhealth.au
P: 0479 077 723

Message

NDIS Referrals

We support self-managed, plan-managed, and NDIA-managed participants. This can be completed by:

Support Coordinators

Plan Managers

Participants and families

Complete our quick referral form to get started — it takes approximately 2–3 minutes.

Consent *

I have gained consent from the participant/client to share this information

Participant / Client Details

Full Name *

Date of Birth

Address

Primary Contact details - Who should we contact (participant/carer/nominee)

Name (optional)

Mobile

Relationship

Phone

Preferred contact method (optional)

Health Background

Primary NDIS condition(s)

Other health/medical conditions

Any Medications (if known)

NDIS Plan Details

NDIS number

Plan Start Date (optional)

End/Review Date (optional)

Funding

Plan Type

Self-managed
Plan-managed
NDIS-managed
Unsure

Funding Category - you can find this on your participant’s NDIS Plan* (tick which option below)

Capacity Building – Improved Health & Wellbeing
Capacity Building – Improved Daily Living
Core – Assistance with Daily Life

*If you are unsure about the correct funding category, you can email us to help guide you.

Invoicing Preferences - who can we send the invoices to?

Name

Support coordinator details (if applicable) (optional)

Name

Phone

Goals

Participant Goals - may be found on their NDIS plan (what would you like to achieve with your exercise physiology program?) (optional)

Participant Goals - may be found on their NDIS plan (what would you like to achieve with your exercise physiology program?) (optional) (copy) (copy)

Participant Goals - may be found on their NDIS plan (what would you like to achieve with your exercise physiology program?) (optional) (copy)

Where would your participant prefer sessions? (tick all that apply)

Session Preferences

Home visits
Gym
Hydrotherapy
Telehealth
Private Exercise Studio
No preference / unsure

Preferred session length (follow up sessions)

Preferred (follow-up) Session Length

60-min
45-min
30-min

How Often

Frequency

Weekly
Fortnightly
Monthly

Anything we should know for safety? Tick all that apply

Safety (standardised)

Behaviour Support Plan (NDIS ONLY)
Seizures
Communication support required
Falls risk
Manual handling required

Upload (BSP, NDIS Plan - relevant sections, any other relevant information applicable to referral) [folder]

Upload your BSP, NDIS plan, or relevant documents.

Upload your BSP, NDIS plan, or relevant documents. You can upload up to 1 files.

Signature

Digital or typed are accepted:

Upload your signature here. You can upload up to 1 files.

Name

Role

Date

Got questions?

Contact the Lead Accredited Exercise Physiologist directly
E: caroline@greaterhealth.au
P: 0479 077 723

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