Empower Healthcare Referral Form – Empower Healthcare Referral Form

At Empower we strive to enable you or the person you care for to achieve their desired health goals and to support them to live their best life.

We take the time to understand each person’s specific requirements and goals and tailor our services to achieve the best results. We see people from the age of 15 years upwards.

The referral form takes only a few minutes to complete and provides us with essential information so that we can get started quickly.

The form has a useful feature that allows you to save and return partially completed referral if needed.

After you submit a referral, we will send you an acknowledgement email with a complete copy of everything you sent us for your records.

If you need any support or have any feedback, please email our team community@empowerhealthcare.com.au
View Terms and Conditions.
NDIS T&C
Home Care T&C
To get started please tell us; in which state is this service required?*
- VIC
- NSW
- WA
- QLD
- SA
- TAS
- ACT
- NT
In Victoria we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Nursing, Occupational Therapy, Osteopathy, Physiotherapy, Podiatry, Speech Pathology
In New South Wales we currently provide the following Homecare and NDIS participant services: Occupational Therapy, Physiotherapy, Podiatry, Speech Pathology
In Western Australia we currently provide the following Homecare and NDIS participant services: Dietetics, Occupational Therapy, Physiotherapy, Speech Pathology
In Queensland we currently provide the following Homecare and NDIS participant services: Dietetics, Massage, Occupational Therapy, Physiotherapy
In South Australia we currently provide the following Homecare and NDIS participant services: Telehealth on request
In Tasmania we currently provide the following Homecare and NDIS participant services: Telehealth on request
In the Australian Capital Territory, we currently provide the following Homecare and NDIS participant services: Telehealth on request
In the Northern Territory we currently provide the following Homecare and NDIS participant services: Telehealth on request

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Referrer (please tell us about you)
First Name*
Last Name*
Position*
Referrers Post Code*
Organisation
Contact Phone Number*
Email*

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Client Details (about the person to provide care to)
Has this Client been seen by an Empower Healthcare clinician previously?*
- Yes
- No
First Name*
Prefers to be called (if different)
Last Name*
Date of Birth*
Gender*
Address*
Street Address Unit/Flat Suburb State Postcode
Type of Home*
- Private Residence
- Aged Care Facility
- SDA (Specialist Disability Accommodation)
- SIL (Supported Independent Living)
- SRS (Supported Residential Services)
- Other
Please provide home type details.*
Notes: Access to Home
Please use this space to provide any instructions we may need regarding access to the client's home.
Hidden
Agent Region Hidden

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Client Contact Details
Who should be our primary point of contact to arrange client appointments with?*
- The Client
- A Relative or other Representative
Please provide at least one contact number
Mobile Number (Preferred)
Other Phone Number
Please provide at least one contact number
Name of Representative*
Relationship to Client*
Mobile Number (Preferred)
Other Phone Number
Please ensure you provide at least one contact number here.
Emergency Contact
In the event of an emergency who should we contact?
Name of Emergency Contact*
Last Name
Relationship to Client*
Mobile Number (Preferred)
Other Phone Number
Please ensure you provide at least one contact number here.
Home Risk Assessment
Are there any issues you are aware of that may impact on client, carer or service provider safety?
- No
- Yes
Please use this space to tell us more about any risks or issues*
If there is a possibility of the Client or family member being aggressive toward the attending Empower clinician, then the Case Manager must be present for appointments. Aggressive or threatening behaviour will not be tolerated and if the service provider feels unsafe at any time they have the right to leave the premises and refuse future treatment.

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Referral Information (NDIS)
Our team provide a range of assessments and assistance for NDIS clients to help with:

Occupational Therapy:
Our Occupational Therapists provide person centred assessments and therapy to help people achieve their goals, participate in daily activities, and gain greater independence, comfort, and safety.

Physiotherapy:
Our Physiotherapists help people gain or improve mobility through services including movement, rehabilitation, maintenance programs, pain management, falls prevention and functional assessments.

Podiatry:
Our Podiatrists treat and monitor all aspects of foot care from biomechanical and footwear assessments to assist with mobility; to general nail care, ingrown toenail management and wound care.

Dietetics:
Our Dietitians provide advice and support across all aspects of nutrition to improve health and wellbeing as well as managing specific conditions.

Nursing:
Our Nursing team provide a broad range of nursing services including, stoma care, changing and care of urinary catheters, continence advice, medication management, wound care, and personal care.

Speech Pathology:
Our Speech Pathology team provide assessment, diagnosis, intervention, and management in the areas of communication and swallowing.

Osteopathy and Allied Health Assistant
services may also be provided. If you would like to request either of these services, please let us know by indicating this in your referral.
Please note that not all servicers are available in all locations – click on this link to see which services are available in your state.
Your Referral*
Please use this space to provide any more information about the services required. The attached Service Model provides an overview of typical services and funding requirements.
Which of these services are required?*
- Occupational Therapy
- Physiotherapy
- Podiatry
- Dietetics
- Speech Pathology
- Nursing
What is the participant’s primary disability that has enabled them to access the NDIS?*

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Nursing Assessment Required
Please choose at least one of the following*
- Medication Management
- Administer Insulin / Diabetes Management
- Catheter Care
- Continence
- Wound Care / Management
- Other...
Nursing Assessment_Other*
Nursing Regularity Required
What is the main reason for the nursing referral?*
Please provide GP Name and Phone.
GP Name
Phone*
GP Practice*
Email
GP Authority
We cannot provide the service you have requested without a signed and dated authorisation from a qualified Doctor (GP or Specialist).
Please provide an authority with this referral. If required, you can access relevant authorisation templates here.
Can you provide documentation for GP Authority?*
We require a signed and dated authorisation letter from a GP or other medical practitioner to be able to provide this service. Are you able to provide that approval with this referral?
- Yes
- No
GP Authority*
In order for us to provide the care service you have requested we will need an authorisation from the client’s GP.
Drop files here or

Accepted file types: doc, docx, pdf, rtf, jpg, jpeg, Max. file size: 512 MB, Max. files: 10.
No_cond*
- By submitting this referral without the required authority, you acknowledge that our Nursing team will endeavour to obtain it. This work will be charged at our standard Nursing hourly rate. The minimum cost for this service is $105.00 invoiced in advance. Click here to acknowledge that you accept these terms.

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Medical Details
Client Communication*
- Client has no problem communicating verbally
- Client has some issues with verbal communication
- Client has limited English
Please note: we will advise you when we have scheduled the appointment. If the client requires an interpreter to be present please ensure that you arrange this accordingly. Thank you.
Please provide more information here*
Client Mobility*
- Independent
- Supervised
- Requires Assistance
Please provide more information here*
Are you able to upload Medical History Files now?*
Examples of acceptable documentation are GP Health Summary, Hospital discharge summary or NSAF (National Screening Assessment Framework).
One of these documents is an essential requirement for all nursing referrals.
- Yes
- No
Relevant Medical History*
Please upload relevant files here.
Drop files here or

Accepted file types: doc, docx, pdf, rtf, jpg, jpeg, Max. file size: 512 MB, Max. files: 10.
If you are not able to upload history please provide details here*
Finally, if you have any other documentation you would like to attach
Please upload here
Drop files here or

Accepted file types: doc, docx, pdf, rtf, jpg, jpeg, Max. file size: 512 MB, Max. files: 10.

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Confirmations*
- Click here to acknowledge that you have read and accept the relevant terms and conditions of service which you can access below.
Terms and Conditions
NDIS Referrals Terms & Conditions
Home Care Package and Private Funding terms and conditions
Consent*
Click here to confirm you have obtained verbal/written consent from the client/guardian to refer and provide their personal health information to Empower Healthcare for further assessment.*
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Name
This field is for validation purposes and should be left unchanged.

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Referral Form

Step 1 of 10

Referrer (please tell us about you)

Client Details (about the person to provide care to)

Client Contact Details

Please provide at least one contact number

Please provide at least one contact number

Emergency Contact

Funding Details

NDIS

Referral Information

Hydrotherapy Approval

Referral Information (NDIS)

Occupational Therapy:

Physiotherapy:

Podiatry:

Dietetics:

Nursing:

Speech Pathology:

Osteopathy and Allied Health Assistant

Nursing Assessment Required

Please provide GP Name and Phone.

GP Authority

Medical Details

Referral Form

Step 1 of 10

Referrer (please tell us about you)

Client Details (about the person to provide care to)

Client Contact Details

Please provide at least one contact number

Please provide at least one contact number

Emergency Contact

Funding Details

NDIS

Referral InformationPlease choose at least one

Hydrotherapy Approval

Referral Information (NDIS)

Occupational Therapy:

Physiotherapy:

Podiatry:

Dietetics:

Nursing:

Speech Pathology:

Osteopathy and Allied Health Assistant

Nursing Assessment Required

Please provide GP Name and Phone.

GP Authority

Medical Details

Referral Information