OT Student Program - External Referral Form

About our OT Student Program

At Life Skills Hub, we are committed to supporting the development of occupational therapy students and providing accessible support to young people. Our OT Student Program supports children/young people who may require additional support or have challenges with funding services, to receive tailored OT supports that addresses their unique needs.

All OT student services, including assessment and intervention planning, will be overseen by a Senior Occupational Therapist at Life Skills Hub. All students are provided with regular supervision and detailed oversight of all activities.

Please note: All referrals will be triaged by our Senior Clinical Team to determine suitability for the OT Student Program. In some instances, our clinical team may determine that a more experienced clinician. In these cases, our team will be in contact with you.

If you would like to learn more about our OT Student Program, see our website: www.lifeskillshub.com.au/OTStudentProgram

Who can refer into the program?

We recognise the differing need of individuals and current gaps in services across different contexts. We accept external referrals from the following:

Other health professionals such as OT's, Speech Pathologists, Paediatricians etc
School representatives
Self-referrals from caregivers and families.

Please note: All clients (and families) must be aware and consenting to the referral prior to completing this form. It is the referrer's responsibility to discuss the terms of the referral and receive consent.

Instructions

Please take a moment to complete the following fields with as much detail as possible. Your insights into the child/young persons strengths, challenges and goals will enable us to craft personalized strategies that promote their success across environments.

Thank you for your dedication to enhancing the educational experience for our students. We look forward to collaborating with you to make a positive impact on young people's development.

Referrer Details

Referred by: *

Position: *

Company / School: *

Contact Phone Number *

Contact Email *

Date of Referral *

Client Information

First Name *

Last Name *

Preferred Name:

Pronoun(s)

DOB *

Child/Young Person Contact DetailsPhone and/or email. If same as Caregiver, please fill out details below.

Parent/Caregiver 1

Parent/Caregiver 2

Name *

Name

Relationship to young person: *

Relationship to young person:

Contact Details: *

Contact Details:

Who will be the primary contact to organise sessions? *

The referrerThe parent/caregiver

Preferred contact times / Method (If possible)

OT Student Referral Information

Select the reason for the OT student referral: *

To work on different goals while the existing OT works on more complex goalsTo undertake an assessment of needs and provide evidence for supports (ie. progress report or strategies for school)Client is private paying and would benefit from cost-effective servicesOther (please specify)

Other

What areas would you like support with for this child/young person? (tick all that apply) *

Please include more information about the specific areas. For example, if fine motor domain; scissor skills, hand stength, handwriting etc or Daily Living skills; cooking skills, shoelaces, dressing etc *

What would be the location of the service? Tick all that apply *

Onsite at Life Skills HubOffsite - School

Name of School

Current Supports

Who is currently involved with the young person and their parent /caregiver?Please briefly include any therapeutic and educational supports, and in what capacity.

Agency

Service Type

Duration/Frequency

Key Contact

Are there any safety risks to be considered? *

YesNo

Please provide details:

Court and Statutory orders: Are there any current orders in place? *

Other:

Additional information

Please upload any documents that will assist us in gathering more information. Examples include: NDIS plan, Assessment Reports, One Plan Documents etc.

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Additional information(any additional information for referral purposes, i.e. needs regarding clinicians, engagement, reasonable adjustments required or cultural considerations, availability etc.)

Name

Date

Signature (Referrer) *

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