CONTACT THE TOTAL REHAB® TEAM

---

READY TO ASSIST YOU IN YOUR JOURNEY

To start the process of us being able to assist, please fill in the form below with as much detail as possible.

• 1. Personal Details.

• First name*
• Last name*
• Phone*
• Email*

• 2. Background Information.

• Are you an...*
  Please selectIndividual Seeking ServicesPlan ManagerCoordinator of SupportAllied Health PractitionerClaims / Rehabilitation ManagerOccupational Therapist seeking workOther
• Organisation
  Please selecticare / LTCSicare / Workers CareEMLGIOTACWorkCover QLDRACQNRMAOther
• Organisation name*
• Please List*
• Please List*
• How are you funded?*
  Please selectNDISSelf FundedInsuranceOther
• How is the client funded?*
  Please selectNDISSelf FundedInsuranceOther
• Please List*
• Who is your funding body?*
  Please selecticare / LTCSEMLGIOTACWorkCover QLDRACQNRMAOther
• Who is the clients funding body?*
  Please selecticare / LTCSEMLGIOTACWorkCover QLDRACQNRMAOther
• Please list*
• Please list*
• Participant Name*
• Participant Email*
• Participant Phone*
• Participant Address*
• Participant DOB*
  DD slash MM slash YYYY
• Primary Diagnosis*
• Participant / Claim Number*
• Plan Start Date
  DD slash MM slash YYYY
• Plan End Date
  DD slash MM slash YYYY
• How is your plan managed?*
  Please selectSelf ManagedAgency ManagedPlan Manager
• How is their plan managed?*
  Please selectSelf ManagedAgency ManagedPlan ManagerUnsure
• Plan Manager Name*
• Plan Manager Number*
• Plan Manager Email*

• 3. How can we help you today?

• Chosen Services*
  • Complex Seating Assessments
  • Assistive Technology
  • Home Modifications
  • Functional Assessment
  • Pressure Mapping Services
  • Manual Handling
  • Training & Education
  • Case Management
  • Employment
• Complex Seating Options*
  • Pressure Assessment
  • Seating and/or Equipment Application
  • Other
• Pressure History
• Pressure Equipment In Place
• Please List*
• Assistive Technology Options*
  • Wheelchair
  • Commode Chair
  • Hoist
  • Bed/Mattress
  • Other
• Wheelchair Options
  • Power Wheelchair
  • Manual Wheelchair
  • Power Add-on
  • Other
• Wheelchair Use
  • Dependant
  • Independant
• Hoist Options
  • Ceiling Track Hoist
  • Floor Hoist
  • Slings
  • Other
• Bed/Mattress Options
  • Adjustable Bed
  • Air Mattress
  • Other
• Please List*
• Adjustable Bed Size*
  SingleKing SingleDoubleQueenSingle + Companion BedKing Single + Companion Bed
• Air Mattress Size*
  SingleKing Single
• Please List*
• Please List*
• Major or Minor Modifications*
  • Major
  • Minor
• Home Modifications Options - Major*
  • Bathroom
  • Toilet
  • Ramp
  • Hoist
  • Rails
  • Access
  • Other
• Please List*
• Home Modifications Options - Minor*
  • Bathroom
  • Toilet
  • Ramp
  • Hoist
  • Rails
  • Access
  • Other
• Please List*
• Functional Assessment Options*
  • Comprehensive Plan Review Assessment
  • Functional Independence Measure (FIM) Assessment
  • Care Needs Assessment
  • Other
• Please List*
• Manual Handling Options*
  • Risk Assessment
  • Develop Manual Handling Procedures
  • Manual Handling Training
  • Equipment Prescription
  • Other
• Please List*
• Training & Education Options*
  • Wheelchair Prescriptions
  • Seating & Pressure Care Assessments
  • Manual Handling
  • Mentoring / Supervision
  • MAT Evaluation
  • Other
• Please provide further details*

• 4. Additional Information.

Δ