Referral

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Please ensure you use your company email.

Referral from TBI Website

Who is this referral for?(Required)

Myself

Someone else e.g family member patient

Where would you like services to be provided?

At home

In a clinic

At work

At another location

Please specify location

Contact Details for Person Receiving the Service

Name(Required)

First Last

Date of Birth(Required)

Mobile phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City Region Postcode

Are there any days or times during the week when the client is NOT be available for their initial appointment?(Required)

Yes

Are there any days or times during the week when you are NOT be available for an initial appointment?(Required)

Yes

Please specify when the client is NOT available (e.g. Monday mornings)

Note that restrictions may result in delays in scheduling the assessment.

Please specify when you are NOT available (e.g. Monday mornings)

Note that restrictions may result in delays in scheduling the assessment.

What type of service is required?(Required)

Post-surgical rehabilitation (excl. cancer surgery)

Cancer rehabilitation

Concussion rehabilitation

Treatment/rehabilitation for musculoskeletal injury/pain

Neurological rehabilitation(e.g. for Stroke, Parkinson, MS)

Fall prevention programme

Respiratory physiotherapy

Other (please specify)

I’m unsure – please contact me to discuss

Please tell us about the service required

Treatment/rehabilitation for musculoskeletal injury/pain & Concussion rehabilitation

Has the injury been lodged with ACC?

Yes

Unsure

Do you have the ACC claim number?

Yes

ACC Claim Number

Was this a work injury?

Yes

Please provide details of person's injury as well as their current issues and needs.

Please provide details of your injury as well as your current issues and needs.

Post surgical rehab

Was the surgery due to an injury, with the injury claim accepted by ACC?

Yes

Do you have the ACC claim number?

Yes

ACC Claim Number

Was this a work injury?

Yes

Please provide details of person's injury as well as their current issues and needs.

Please provide details of your injury as well as your current issues and needs.

Cancer Rehab

Has any external funding been pre-approved for cancer rehabilitation sessions?

Yes

Please provide funding details

Has the person requiring the services had cancer-related surgery?

Yes

Was the surgery performed in a private hospital?

Yes

Insurance section

Does the person requiring the services have private health insurance?

Yes

Please state the name of the health insurance provider and the policy type

Please provide details of person's medical condition as well as their current issues and needs.

Please provide details of your medical condition as well as your current issues and needs.

Contact Details for the Referrer

Referrer Name(Required)

First Last

Referrers organisation OR relationship to person requiring service(Required)

Referrer Phone(Required)

Referrer Email(Required)

Section Break

Date

Please select closest clinic

Please select your region

Northland Clinics

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Auckland Clinics

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Waikato Clinics

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Bay of Plenty Clinics

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Gisborne Clinics

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Hawkes Bay Clinics

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Taranaki Clinics

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Manawatu/Whanganui Clinics

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Wairarapa Clinics

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Wellington Clinics

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Marlborough Clinics

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Tasman Clinics

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Canterbury Clinics

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West Coast Clinics

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Otago Clinics

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