NDIS Registered Provider

HILLARYS & EAST VICTORIA PARK

Call us to book your assessment | 0478 205 945 | Fax: (08) 6314 6658

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Referral Form
Vehicle Modifications
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Home
Services
Referral Form
Vehicle Modifications
Resources
Join Our Team
Contact Us

Home
Services
Referral Form
Vehicle Modifications
Resources
Join Our Team
Contact Us

Home
Services
Referral Form
Vehicle Modifications
Resources
Join Our Team
Contact Us

Home
Services
Referral Form
Vehicle Modifications
Resources
Join Our Team
Contact Us

NDIS Occupational Therapy Driver Assessment Referralsadmin2025-08-07T15:43:12+10:00

REFERRAL FORM

Our Occupational Therapy Driving Assessments are based in Hillarys and East Victoria Park. Home visits are available on request. To begin the process, please contact us directly or via your medical practitioner to get a referral for DriverRehab.

Fill in the form below or download a copy by clicking the button.

Download form

NDIS Referrals Form

Name(Required)

First Last

Date of Birth

Day

Month

Year

Location/Suburb(Required)

Phone(Required)

Alternate Phone

Email(Required)

Is the person an NDIS participant?(Required)

Participants NDIS Number(Required)

Current Plan Start Date(Required)

Day

Month

Year

How is this plan managed?(Required)

Agency Managed

Plan Managed

Self managed

Who is the Plan Manager?(Required)

Who is the participant receiving funding from?(Required)

If other, please specify

Participants Medical Condition/Disability

Date of Disability Onset(Required)

Day

Month

Year

Name of GP(Required)

Medications(Required)

Has the person been medically cleared for a functional driver assessment?(Required)

Yes

Are vehicle modifications required?(Required)

Yes

Drivers Licence / Learner Permit Number(Required)

State of Issue(Required)

Expiry Date(Required)

Day

Month

Year

Is the participant a first time driver?(Required)

Yes

Has the participants licence been suspended?(Required)

Yes

Do you prefer manual or automatic vehicles?(Required)

Manual

Automatic

Is this assessment for:(Required)

C Class Private Licence

Heavy Vehicle Licence

Referring Agents Name(Required)

First Last

Title(Required)

Organisation Name(Required)

Phone(Required)

Email(Required)

Referring Agents Signature

CAPTCHA

About Driver Rehab

At DriverRehab our team of therapists are experienced in conducting occupational therapy driving assessments, prescribing vehicle modifications and monitoring driving lessons for people with injuries, illness or disabilities.

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Contact DriverRehab

Contact our head office below:

21 Endeavour Rd,
Hillarys WA 6025

0478 205 945
Email Us

NDIS Registered Provider

Our Occupational Therapy Driving Assessments are based in Hillarys and East Victoria Park. To begin the process, please contact us directly or via your medical practitioner to get a referral for DriverRehab. Please note the deposit payable by fee for service clients is strictly non-refundable.