ANTS Referral Form

Please indicate your role: *

I am a Health Professional referring a patient / clientI am a patient / client referring myselfI am a Support Coordinator, Carer, or Guardian making a referral on behalf of someone else

Referral date *

Referrer Information

Referrer Details

Referrer's First Name *Individual making the referral

Referrer's Last Name *

Organisation

Contact Details

Referrer's Phone *

Other Phone

Referrer's Email *

Fax

Referrer's Address

Street

Suburb

State

Postcode

ANTS Referral Form

Client Information

Client Details

First Name *

Last Name *

Gender *

Date of Birth *

Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait IslanderBothNo

Occupation

Client has a legal guardian *

YesNo

Please provide guardian name and contact details *

Client requires an interpreter *

YesNo

Please indicate language *

Client Contact Details

Client Email *

Client Phone

Specify best contact for appointments (if not client, please enter name, relation to client, and contact number and email) *

Additional contact information

Client Address

Street *

Suburb *

State *

Postcode *

Funding Details

Funding Type *

Self-Funded - By selecting this option, you confirm that no financial support is being provided by the NDIS or any other third party.NDIS - Please provide NDIS number, plan type (e.g. self-managed, plan-managed, NDIA-managed), and plan dates.Insurance / WorkCover - Please provide insurer name, claim number, and case manager contact details.Other - (e.g. Legal Aid, Third-Party Organisation) - Please specify:

Insurer *

Case Manager details *

Insurance Case/Claim Number *

Plan Management Option *

Participant (Self managed / Managed by nominee)Plan Management ProviderNational Disability Insurance Agency (NDIA)

NDIS Number *

NDIS Plan Manager *

NDIS Plan End Date *

Other funding details (e.g., funding periods). *

Referral Considerations

Reason for referral *

Neuropsychological Assessment/TestingTreatment/InterventionBehaviour SupportsANTS Programs (e.g. Cognitive Remediation Program, ACE Flex, other)Remote Online Cognitive Assessment (if eligible)

Please provide details on reason for referral *

Already have a referral from a health professional? Upload it here

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How did you hear about us?

ANTS Referral Form

Client Functioning and History

Further details on these Neuropsychological Complaints / Suspected Neuropsychological Weaknesses

Further details on Mental Health Diagnosis/Treatment

Further details on current medications

Supporting documents

Please upload here any supporting documents that may be relevant for the clinical team (pdf files preferred)

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i.e., previous psychological or neuropsychological assessments, OT reports, MRI reports, discharge summaries, NDIS goals. (Background documentation review for neuropsychological assessments is capped at 90 pages - further document review may incur in additional charges)

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