Third Party Referral Form - Optimum Intake

This third-party referral form allows healthcare professionals, support coordinators and service providers to refer clients to Optimum Intake for dietetic and nutrition support. Our accredited practising dietitians work collaboratively with referrers to provide evidence-based, client-centred care tailored to individual needs. Complete the form below and our team will review the referral and contact you with next steps.

Client name

Date of birth

Address

Phone

Emergency contact

Emergency contact number

Relationship to client

Who shall we contact to book the appointment?

Name

Phone

Relationship to client

Case Manager

Case manager name

Organisation and role

Case manager phone

Case manager email

Main reason for referral to Dietitian:

Invoicing Details:

Which office/department/organisation is responsible for payment of services?:

Organisation

Claim number

Approval number (if relevant)

Invoice to be sent to email

Initial Assesment

The initial evaluation enables the clinician to conduct a comprehensive assessment, engage in goal discussions, and establish a future plan. Following the initial assessment, a report outlining suggested interventions and associated costs will be sent to you for your review. We will not proceed with any additional services until we receive your written approval, which you can provide by signing the final page of the report.

Initial Assessment and Report:
Clinic Visit: $425Home Visit: $505 (includes travel**)

Do you require a formal quote on letterhead before proceeding with the initial appointment?
YesNo

Does this person have a GP referral?
YesNo

If so, do they also have a care plan (Chronic Disease Management Plan, Mental Heatlh Care Plan or Eating Disorder Plan)

Does this client have an NDIS Plan?
YesNo

Any additional information to assist with proceeding with assessment and /or treatment? Any safety issues present?

*Service Fee as of July 2024 - subject to change as required:

NOTE- these fees are provided for informaion purposes only. Subsequent sessions following the initial assessment will be detailed and costed in the initial report, and further services will not be provided until signed approval received.

Clinic Based Initial Assessment: $425 (includes report)

Home Visit Initial Assessment: $505 (includes report and includes travel charge*)

*Extra travel fee may apply if travel is more than 30mins each way.

Please note: 48hrs notice is required for any cancellations, otherwise full fee is charged.

Form Completed by:

Name

Position

Organisation

Phone

Date