Make a Referral

Looking to access Superyou therapy services for yourself or someone else?

You don’t need a referral from a GP or specialist, simply fill out our form below and we will be in touch within 2 business days!

Superyou Referral Form

Step 1 of 7

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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 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: 50 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: 50 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

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

⚡

Find out more about our Specialised Services here

⚡

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

Max. file size: 50 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

Unsure

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 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?

Phone

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

Make a Referral

Make a Referral

Make a Referral

Superyou Referral Form

Referrer Details (person completing this form)

Client Details (person receiving services)

Primary Contact

Funding

Client Services

Risk Assessment

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