Alissa Terlich OT (ATOT) is a highly respected provider of Mental Health Occupational Therapy services in Melbourne's northern suburbs.

We offer a range of evidence-based, trauma-aware, and neuroaffirming services designed to support individuals in achieving their goals, building capacity, and finding greater meaning in life. Our approach fosters a trusting and supportive environment where you can explore what matters most to you while developing skills to nurture your mind, body, and spirit.

ATOT provides capacity-building, psychological, and sensory-focused services both in-person and via Telehealth across Melbourne.
For those in rural areas, Telehealth sessions are available.

Referral Form

ATOT has requested the following information to be able to proceed with this referral:

Please provide the further context or documentation using the form fields below
and click "Submit" at the end of the form to send this information back to ATOT.

If you are having any difficulties please contact us at hello@alissaterlichot.com

Date *

Client Details

First Name *

Last Name *

Date of Birth *

Known As

Phone Number *

Email

Address *

Please provide any additional information regarding access to the property

Cultural Considerations

Is this person under the care of a Public Guardian? *

YesNo

Guardianship information (name and contact details) *

Please specify *

Primary Diagnosis as recognised by NDIS/Specialists *

Relevant Medical History *

Preferred delivery of Services *

Face-to-Face MelbourneTelehealthEither/Combination

Contact preference *

Please advise of the current situation and what you are requesting from OT supports *

Any other reports or documents that may assist with Services for the Client

Browse

Client Representative

First Name

Last Name

Relationship to Client

Contact Phone Number

Contact Email

If there is an Advocate in place, please specify their information below

Advocate name, contact details and organisation

Referrer Details

First Name *

Last Name *

Organisation

Referrer's relationship to Client *

Other relationship

Referrer Phone

Referrer Email *

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Additional Stakeholders involved in this Client's care

Funding Information

Funding Source *

NDIS Self ManagedNDIS Plan ManagedPrivate

NDIS Number *

Plan Start Date *

Plan End Date *

Plan Manager Company *

Invoicing Email *

Occupational Therapist Hours available - please specify *

Occupational Therapist Dollars

Send Service Agreement to *

Contact for arranging appointments *

If the Client consents, please upload a copy of the NDIS Plan if able

Browse

Please provide any documentation from the GP or other Allied Health professionals

Browse

Risk Factors

These risks may entail any persons present at the appointments or location, or involved in this Client's care

I will liaise with the Therapist to provide a support person for all visits for this Client (if identified by the Therapist that 2 people present is required) *

The risk information above is given with honesty and the answers are to the best of my ability *

Director Review

This Client is suitable for services *

YesNoNeed further info

If you require more information from the Referrer/SC before approving this Client, please use the checkbox option “Needs further info” A text box will pop up. Please enter the further information required into this box. This text will automatically be sent back to the Referrer/SC via the auto workflow email. The Referrer can then provide the additional info before you progress to accepting the Client and the following setup by Admin.

Please describe what further info is required from referrer *

If no provide reasoning: *

Any further information for Admin

Allocated Therapist *

Therapist Email *

Ideal time frame for providing services

Review by OT

I accept this referral: *

YesNo

If no, please provide reasoning: *

Any other notes for Alissa or Admin?

I am aware that the ideal time frame for providing services is:

I will liaise with the following person regarding appointments:

Director Finalisation

Next Steps *

Admin setup case file in Splose & AsanaAdmin send SA

Ongoing Support hours or dollars for SA

Any other notes for Admin?

Admin Actions

First Steps *

Setup Client in Splose - if no Client own phone or email please enter the Rep's details in these fields so as to prompt reminder - "SMS" ONLY FOR REMINDERS;Reason for Referral added to 'Other Details' during setup;Client Representative and Referrer added to 'Other Details' text box and as Contacts;Attached files uploaded (create a Referral Information folder if required) including Ref Form that comes through when completed;Any extra emails re this referral in hello@ added to Correspondence Folder (create if needed);Therapist tag selected, along with funds management type;"Contact details" tag and dropdown field entered;

This Client is SELF MANAGED - please assign the Bill-To as their email address - turn on invoice reminders *

This Client is PLAN MANAGED - please assign the Bill-To as per info in form - turn on invoice reminders *

Case budget setup in Splose.
- Please title Surname dd.mm.yy - dd.mm.yy
- Type: Hours
- Case Alert: 70% and 4 weeks out to Assigned Therapist
*

Second Steps

Risks added into communication log and notes updated in Alerts;

NDIS Plan dates and NDIS No. added into Splose Date fields

ATOT Service Agreement

Please add "Person to liaise with for appointment" an associated contact and select appt

Set up (Start date is DATE OF REFERRAL) and Send SA to Client/Representative or OT only as requested

If this is an OPG Client do NOT put their specific email address in Authorised Representative email field, JUST LEAVE BLANK, and put n/a for Client email. Make sure you include the SC email in the SC email field.

Please add tag Unsigned SA in Splose - include link to SA in Alerts
Please add "Pending SSA" to name in Asana and choose the Pending SA tag

Send to Client

Send to Rep

Send to Referrer

Send to Therapist

Client created and updated in Asana;
Comment on the Asana client profile as 'SA Sent for signing dd.mm.yy - (link to SA)';
Create a follow up subtask for remind the OT each 7 days until returned;
Create a follow up subtask to remind the Client/SC each 3 weeks until returned; *

Upload documents and this completed referral to Splose when the workflow email comes through post completion *

Team member completing this Form

Save and Complete Later