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3 Locations Around Perth

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

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Referral Form
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Home
Services
Referral Form
Vehicle Modifications
Resources
Book Assessment

Home
Services
Referral Form
Vehicle Modifications
Resources
Book Assessment

NDIS Occupational Therapy Driver Assessment Referralsadmin2023-11-30T16:36:38+10:00

Referrals Form

Our Occupational Therapy Driving Assessments are based in Hillarys, Manning and Midland, Western Australia. 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.

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NDIS Referrals Form

Name(Required)

First Last

Date of Birth(Required)

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

Day

Month

Year

How is this plan managed?

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(Required)

Date of Disability Onset

Day

Month

Year

Name of GP

Medications

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?

Yes

Do you prefer manual or automatic vehicles?(Required)

Manual

Automatic

Is this assessment for:

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
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Referrals Form

NDIS Referrals Form

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