Make A Referral For Perth NDIS Therapy & Collaborative Supports!

Start Your Journey With Superyou!

Complete a referral form and a Superyou Client Relationship Officer will be in touch within 2 business days.

Please select your funding source to begin:

NDIS FUNDING

This means you intend to use funding from an NDIS plan or other funding source to cover all or some of the cost of therapy sessions, such as:

NDIS
Insurance Commission of WA (ICWA)
Department of Communities – Continuity of Support (COSA)
Department of Communities – Child Protection and Family Support
Department of Health & Aging

NDIS Referral Form

Step 1 of 8

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This field is for validation purposes and should be left unchanged.

I am making a referral for(Required)

Myself

A family member or friend

A client/participant I am supporting

Other

Referrer Details (person completing this form)

Your Name(Required)

First Last

Organisation (if applicable)

Email(Required)

Phone(Required)

Preferred method of contact (referrer)(Required)

Any

Phone Call

Text Message

Your relationship to client (referrer)(Required)

Relationship(Required)

Client Details (person receiving services)

Client Name(Required)

First Last

Preferred Name

Preferred Pronouns

Date of birth(Required)

Day

Month

Year

Other - Please provide

Address(Required)

Address Suburb State Post Code

Client Email(Required)

Client Phone(Required)

Preferred Superyou Location for Services(Required)

Preferred method of contact (client)(Required)

Any

Phone Call

Text Message

Gender(Required)

Primary Disability(Required)

Please specify (other disability)(Required)

Secondary disability/other details

Indigenous Status(Required)

Are there any cultural beliefs, practices, or traditions that we should be aware of to provide the most respectful and effective services for the client? Please specify any preferences or considerations for therapy sessions?

Interpreter required?(Required)

Yes

Language spoken at home(Required)

Interpreter details(Required)

Primary Contact

Who is the Primary Contact?(Required)

The Client

The Referrer (you)

Someone Else

The Primary Contact is the person authorised to sign a service agreement for the client and receive communications.

Client Email(Required)

Client Phone(Required)

Preferred method of contact (client)(Required)

Any

Phone Call

Text Message

Contact Name(Required)

First Last

Contact Organisation (if applicable)

Contact Email(Required)

Contact Phone(Required)

Preferred method of contact (primary contact)(Required)

Any

Phone Call

Text Message

Relationship to client(Required)

Relationship(Required)

Funding

Funding Source(Required)

How will the services be funded/paid for?

NDIS Number(Required)

GP Name

The name of the GP that referred you

Referral Date

Day

Month

Year

Please upload a copy of your GP Referral

Max. file size: 200 MB.

Funding Management Type(Required)

Self Managed

Plan Managed

NDIA Managed

Plan Management Organisation(Required)

Manage It Plan Manager(Required)

Email(Required)

Please enter the email address to send invoices to

Plan Start Date(Required)

Day

Month

Year

Plan End Date(Required)

Day

Month

Year

NDIS Plan

Max. file size: 200 MB.

Please upload your NDIS plan, or the goal pages of your NDIS plan. This helps ensure the referral goes to the most appropriate therapist in Superyou

Scheduling Contact(Required)

Please select the best person to contact to receive information regarding scheduling appointments.

Scheduling Contact Name(Required)

Scheduling Contact Email(Required)

Client Services

What services are required? (Please select all that apply)(Required)

Occupational Therapy

Speech Pathology

Physiotherapy

Does the client require a functional capacity assessment?(Required)

Yes

Functional Assessment reason(Required)

Does the client require any of our specialised services? (Please select all that apply)

Animal Assisted Therapy

Assistive Technology

Driving

Home Modifications

Mealtimes

Home Automation, Gaming and Computer/Tablet Access

AAC (Communication Device)

Specialist Disability Accommodation

What is the clients current drivers licence status?(Required)

Drivers Licence Number

Drivers Licence expiry date

Day

Month

Year

Description of services you are seeking, including your therapy goals(Required)

By providing us with detailed information about your needs and goals, you're helping us tailor our services specifically to meet your requirements. The more info the better, so please provide us all the info you can in this section.

Preferred Location for Services(Required)

Home

School

Community

Superyou Clinic

Community Location(Required)

School Name(Required)

Is there anything we need to consider when scheduling appointments?

E.g. preferred days/times

Risk Assessment

Is the client transitioning from another provider?(Required)

Yes

Are there any transition concerns?(Required)

Does the client have any anxiety triggers or preferences we should be aware of as part of service provision?(Required)

Yes

Unsure

Please provide additional details (Anxiety)(Required)

Does the client have swallowing difficulties, including a risk of choking or aspiration?(Required)

Yes

Unsure

Please provide additional details (Swallowing Difficulties)(Required)

Does the client have a mental health diagnosis?(Required)

Yes

Unsure

⚡️Important Note on Scope of Practice – Mental Health Diagnoses⚡️

As we are not a specialised mental health service, there are certain conditions that fall outside our scope of practice. This means we are unable to provide therapy for goals that are directly related to the following diagnoses:

- Eating Disorders
- Personality Disorders
- Obsessive Compulsive Disorder (OCD)

However, we may still be able to provide therapy for clients who have these diagnoses, if:

- The therapy goals are unrelated to these conditions (e.g. supporting someone with an eating disorder to trial a new wheelchair),
- The client has a medical and/or mental health team in place for support with the above conditions,
- A suitable clinician is available with the relevant experience and capacity

Mental Health Diagnosis (Please select all that apply)(Required)

Anxiety

Bipolar

Depression

Schizophrenia

Self Harm

Suicidal Ideation

Psychosis

Please provide additional details (Mental Health Diagnosis)(Required)

Does the client have a history of antisocial behaviour, criminal convictions or violence restraining orders?(Required)

Yes

Unsure

Please provide additional details (Antisocial behaviour)(Required)

Does the client have a history of inappropriate sexualised behaviour?(Required)

Yes

Unsure

Please provide additional details (Sexualised Behaviour)(Required)

Does the client have issues with alcohol or illicit substance abuse?(Required)

Yes

Unsure

Please provide additional details (Illicit Substances)(Required)

Does the client have a positive behaviour support plan in place?(Required)

Yes

Unsure

Please upload a copy of the positive behaviour support plan(Required)

Max. file size: 200 MB.

This can be emailed to hello@superyou.org.au if you don't have to hand right now

Will anyone else be present during therapy visits?(Required)

Yes

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Please let us know who they are and if they may present any risks to our therapists including whether they have any past criminal convictions or violence restraining orders, they display inappropriate sexualised behaviour, they have issues with alcohol or drug abuse, they have a history of antisocial behaviour, or they have an active, non-managed mental health diagnosis?(Required)

Are there any domestic hygiene issues in the client home?(Required)

Yes

Unsure

Please provide additional details (Domestic Hygeine)(Required)

Does the client have a known or suspected infectious disease (e.g., MRSA, Hepatitis B/C, Tuberculosis) that may pose a risk to others or require specific infection control measures?(Required)

Yes

Unsure

Please provide additional details regarding suspected infectious disease(Required)

Does the client or other people in the client home smoke or vape?(Required)

Yes

Unsure

Please provide additional details (Smoking/Vaping)(Required)

Are there any pets in the client home?(Required)

Yes

Unsure

Please provide additional details (Pets)(Required)

Are there any other risks our staff should know about?

Risk Acknowledgement(Required)

I confirm that all information I have provided relating to risks is true and accurate to the best of my knowledge

How did you hear about us?(Required)

Support Coordinator

Local Area Coordinator

NDIS Planner

Other Allied Health Professional

Google/Bing

Social Media

Radio

Word of Mouth

Event/Expo

Other

Is there any other information you would like to share?

OPTIONAL ONBOARDING APPOINTMENT (30 MINUTES)

Book an optional discovery appointment to help you get set up faster and access services sooner.

Select “Yes” below to choose a date and time.

Would you like to schedule an obligation-free 30-minute discovery appointment?(Required)

Yes

This Discovery Meeting gives you the opportunity to explore what services with Superyou Therapy may look like, while helping us understand what matters most to you. You’ll meet with our Clinical Manager and Client Relationship Officer to discuss your goals, explore suitable services, and thoughtfully match you with the clinician best suited to support you. This meeting will ensure a collaborative onboarding process to support your journey to start smoothly.

CHOOSE AN APPOINTMENT DATE AND TIME

Please click the button below to book your discovery appointment. The booking link will open in a new tab so you can return to this form.

Book your onboarding appointment

Once you’ve selected a time, one of our Client Relationship Officers will be in touch to confirm your appointment.

PRIVATE PAYING

This means you intend to use your own funding to cover the total cost of therapy sessions.

Private Paying (Fee for Service)
Private Health
Medicare

If you are claiming a Medicare rebate, you will require a specific referral from your GP

Private/Self-funded Referral Form

Step 1 of 6

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This field is for validation purposes and should be left unchanged.

Form Start

I am making a referral for:(Required)

Client / Referrer Details

Client Name(Required)

First Last

Preferred name

Gender(Required)

Pronouns

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client email(Required)

Client phone number(Required)

Preferred method of contact (client)(Required)

Any

Phone

Text message

Primary Disability(Required)

Secondary Disability/Other details

Indigenous Status(Required)

Language/s Spoken at Home(Required)

Do you require an interpreter?(Required)

Yes

Interpreter Details(Required)

Funding Information

Funding source(Required)

Private Paying

Medicare

Private Health

Medicare GP Referral(Required)

Max. file size: 200 MB.

Please upload your GP referral to access Medicare funding

Scheduling contact(Required)

First Last

Please select the best person to contact to receive information regarding scheduling appointments

Scheduling email(Required)

Please enter the email address to send invoices to

Client Services

What services are required? Please select all that apply(Required)

Speech Pathology

Occupational Therapy

Physiotherapy

What is the main Speech Pathology area you'd like support with?(Required)

Speech & Sound Development

Speech sound differences / unclear speech

Stuttering / fluency difficulties

Language & Understanding

Late to talk

Difficulty understanding instructions

Difficulty expressing ideas, thoughts or needs

Social Communication

Social interaction with peers

Social use of language (eg conversational skills)

Feeding & Swallowing

Picky or restrictive eating

Difficulty chewing or swallowing

Literacy Skills

Reading & Writing Development

What is the main Occupational Therapy area you'd like support with?(Required)

Daily Living & Independence

Self-care (dressing, toileting, feeding)

Independence with routines

Home or school participation

Sensory Processing & Emotional Regulation

Sensory seeking or avoiding behaviours

Emotional regulation / Challenging behaviours

Overwhelm or meltdowns in daily environments

Fine Motor & Visual Motor

Handwriting difficulties

Scissors, drawing, fine motor control

Play & Engagement

Play skills and exploration

Attention and engagement in tasks

Participation & Function

Difficulty engaging in school, childcare or community settings

Challenges with transitions or changes

What is the main Physiotherapy area you'd like support with?(Required)

Gross Motor Development

Concerns meeting typical milestones (running, jumping, stairs)

Difficulty keeping up with peers physically

Awkward or inefficient movement patterns

Balance & Coordination

Frequent falls

Balance or stability

Pain or Physical Discomfort

Pain affecting participation

Mobility limitations

Do you need a report for your assessment?(Required)

Yes

Unsure

(Optional) Tell us more about the support you're seeking (this helps us match you with the right clinician)

Risk Assessment

Is this client transitioning from another provider?(Required)

Yes

Unsure

Please provide names and details for any previous providers(Required)

Does the client have any anxiety triggers or preferences we should be aware of as part of service provision?(Required)

Yes

Unsure

Please describe these triggers and/or preferences(Required)

View our Private Paying Service Agreement Terms and Conditions here before accepting.

Do you agree to Superyou Therapy Private Service Agreement Terms and Conditions?(Required)

Yes

Make a Referral

Start Your Journey With Superyou!

NDIS Referral Form

Referrer Details (person completing this form)

Client Details (person receiving services)

Primary Contact

Funding

Client Services

Risk Assessment

OPTIONAL ONBOARDING APPOINTMENT (30 MINUTES)

CHOOSE AN APPOINTMENT DATE AND TIME

Private/Self-funded Referral Form

Form Start

Client / Referrer Details

Funding Information

Client Services

Risk Assessment

start your journey with superyou therapy