Online Referral Form | Diverge Neuropsychology

Client

Need to upload a file? There is a document upload feature at the very end of this form.

* required

Name*

Address*

State and postcode*

Phone*

Email*

Add preferred mode of communication

(e.g. text, email, phone call)

Best time to contact

Date of birth*

Country of birth

Gender*

Male
Female
Other

Aboriginal/TSI*

Yes
No

Language spoken other than English

Interpreter required?

Yes
No

Covid vaccination status

Do you have a vaccination certificate available?*

Yes
No

Referrer

(Please include your Provider Number if you have one)

Name*

Date of referral*

Role*

Provider number

Agency*

Phone*

Email*

Mobile*

Postal address*

Reason for referral*

Type of service required

(tick all that apply. See ‘Services’ page on website for further explanation if needed)

Behaviour Assessment

Behaviour Assessment
Neuropsychology Assessment
Behaviour Support Intervention
Counselling

Funding Source:*

NDIS
TAC
Worksafe
DHHS/Corrections
Other (medicolegal, medicare, private)

DHHS ADDITIONAL REQUIRED INFORMATION

Please provide the following information:

Name of DHHS support co-ordinator*

DHHS branch address*

Contact phone number of support co-ordinator*

Email address of support co-ordinator*

Funding details

Name and address for invoicing*

Email address for invoicing*

If more than one DHHS branch involved, please provide further details:

NDIS ADDITIONAL REQUIRED INFORMATION

All questions below need to be answered before an NDIS funded referral can be considered.

NDIS PLAN NUMBER*

NDIS PLAN DATES

START DATE*

END DATE*

MANAGING PLAN FUNDING (Please tick one)*

Note: we only accept clients who are NDIS Plan Managed or Self-Managed. We DO NOT see Agency/NDIA Managed clients.

Self-Managed: (invoices directly to client or guardian)
Plan- Managed: (Invoices directly to Plan Management organisation)

How many NDIS funded hours (if known) are allocated to neuropsychology services?

Details of guardian (including email address) for invoicing*

Details of plan management agency (including email address) for invoicing*

Budget line items

(Please tick relevant line item/items)
Please note Diverge is registered to provide neuropsychology services under the following categories:

Capacity Building - Improved Daily Living Skills Therapy Supports (15_054_0128_1_3)

15_054_0128_1_3 - Assessment, Recommendation, Therapy and/or Training (including Assistive Technology) - Psychology * Provision to a participant of Assessment, Recommendation, Therapy or Training (including in assistive technology) supports * The support must be delivered by a Psychologist

Number of hours and/or funds available to Diverge?*

Core - Assistance with Daily Life Therapy-related health supports (01_701_0128_1_3)

01_701_0128_1_3 - Assessment, Recommendation, Therapy and/or Training (including Assistive Technology) - Psychology * The support must be delivered by a Psychologist

Number of hours and/or funds available to Diverge?*

Please provide a copy of the plan, or excerpts of the plan relevant to neuropsychology services. All the above questions need to be answered before the referral can be considered.
(Please use the upload feature below to attach any relevant documentation, eg. copy of plan, excerpt of plan)

TRANSPORT ACCIDENT COMMISSION ADDITIONAL REQUIRED INFORMATION

Please provide the following information:

TAC claim number*

Date of accident*

Name of support co-ordinator*

Contact phone number of support co-ordinator*

Email address of support co-ordinator*

WORKSAFE VICTORIA ADDITIONAL REQUIRED INFORMATION

Please provide the following information:

WorkSafe claim number*

Date of accident*

Name of Worksafe agency*

Name of Worksafe claim manager*

Contact phone number of claim manager*

Email address of claim manager*

Referral by medical practitioner

A medical practitioner must provide a referral for psychology services prior to commencement of treatment. WorkSafe considers psychology to be a referred service.

Name and phone number of referring medical practitioner*

Provider number*

OTHER ADDITIONAL REQUIRED INFORMATION

Please provide your mental health treatment plan

Private referral
Self Referral
Other

Case Manager, GP*

Request a quote

Funding and invoicing details

Please provide funding details*

Please provide name and address for invoicing*

Email address for invoicing*

Please describe main issues to be addressed*

(e.g., capacity assessment, return to school, staff or family education, family relationship difficulties etc)

Acquired brain injury

(If the person has ABI, please give details of date and cause of injury)

Rehabilitation

(Please use the upload feature below to attach any relevant reports e.g., discharge summary, neuropsychology assessment)

Other medical history

(medical past or current medical issues of note, e.g., trauma, seizures, pain, blood pressure, diabetes, incontinence)

Mental health

Current medications

Alcohol/other drug use

Behaviour

(e.g., verbal or physical aggression, socially or sexually inappropriate behaviour, wandering, absconding, lack of initiation)

Cognition

(e.g., concentration, memory, planning, reasoning, insight)

Communication issues

Physical issues

Sensory issues

(e.g. hearing or visual impairment)

Developmental issues

(e.g. complications during the pregnancy, birth or development)

Any other issues that you think it is important for us to know?

Previous assessments

Please provide details of any previous assessments that have been carried out (e.g. cognitive assessments, speech pathology assessments, etc.)? To add an assessment please use the 'Add assessment' button.

Type of assessment:

Date/year:

Name/organisation of assessor:

Edit
Delete

Legal issues

(e.g. Youth Justice, Family Court, Child Protection)

Custody arrangements (if applicable):

Restrictions on release of information (if applicable):

Education/childcare*

Please choose*

Adult
Child/young person

Adult

Education level completed

Best subjects

Any literacy/ maths difficulties

Child/Young person

Type of Institution:

Childcare Centre
Kindergarten
Primary School
Secondary School
P-12 School
Specialist School
TAFE
Other (please specify)

Other type of institution

Level/grade

Name of Institution

Address

Postcode

Office phone*

Key contact person

Role

Phone*

Email*

Has your child previously received any special assistance at school/kinder

(e.g. integration aide, reading program, ILP?)

Particular issues/concerns relating to education at the moment

Please describe your child’s strengths or interests

If there any sensitive information that you would prefer not to discuss in front of your child, what is the best way for us to discuss this with you?

(e.g. by phone, separate meeting)

Work history

Previous work history

Current occupation

Current interests and hobbies

Support network

(Please give contact details where applicable, use the ‘Add’ button to add more support network contacts)

Name:

Relationship with client:

Phone:

Email:

Edit
Delete

Name:

Relationship with client:

Phone:

Email:

Edit
Delete

Name:

Relationship with client:

Phone:

Email:

Edit
Delete

Do any family members require an interpreter?*

Yes
No

Which family members?*

What language(s)/dialect?

Any issues related to family life that you would like us to be aware of?

Other relevant family member or friends

Service providers

Please include provider name, contact phone and email

Case Manager

Occupational Therapist

Physiotherapist

Speech Pathologist

Recreation

Dietician

Other Therapist

G.P.

Guardian

Administrator

Others

(e.g., work and study contacts, attendant care agency, advocate, medical specialists etc)

UPLOAD supplementary reports here

Max. file size: 128 MB.

Cancellation policy
Please note that we require at least 24-hours advance notice regarding cancellation of appointments, otherwise a cancellation fee may apply.

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