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Clinician Referral — Continuum Teletherapy & Allied Health

Thank you for referring to Continuum Teletherapy & Allied Health. We'll respond within 1 business day to confirm receipt. For urgent referrals, please also email support@continuumteletherapy.com.au.

This form takes under 2 minutes to complete.

💡 New to Continuum? See our clinician FAQ — including what happens after you refer, whether you'll receive a report back, and our NDIS registration status.

Referring Clinician's Name

Practice Name

Email Address

Best Contact Phone Number

Patient Name

Patient Date of Birth

Patient Contact Number

Is this patient NDIS-funded?

Is this patient NDIS-funded?
A
B
C

Does the patient have a carer, guardian, or support coordinator involved in their care?

Does the patient have a carer, guardian, or support coordinator involved in their care?
A
B

Reason for Referral

What to include — by referrer type:

🩺 GP / MedicalPatient age, diagnosis, why dental care has been deferred, any medications or conditions affecting oral health, urgency.🦷 Dentist / Oral HealthClinical findings, reason standard care cannot be provided (e.g. anxiety, access, complexity), services needed, any imaging or notes to share.🧠 Allied HealthPatient's presenting condition, how oral health intersects with their care (e.g. dysphagia, self-care barriers), goals of referral.📋 Support CoordinatorNDIS participant details, plan type (self/plan/agency managed), funding category, support needs, and any communication or access requirements.

Urgency

Urgency guide🟢 RoutinePatient is stable, no immediate risk. Appointment within 4–6 weeks is acceptable.🟡 Within 2 weeksTime-sensitive need but not in crisis. E.g. upcoming NDIS plan review, deteriorating oral health.🔴 UrgentRequires attention within 48–72 hours. E.g. acute pain, patient at risk, NDIS plan about to expire.

Services Requested

Services Requested

Additional Notes (optional)

This is a good place to include anything that will help us prepare for the patient's first contact. For example:

💊 Medications: "Patient is on blood thinners and has a latex allergy."

🗣️ Communication needs: "Patient is non-verbal and uses AAC. Please liaise with their carer for all scheduling."

🚫 Access requirements: "Patient has significant dental phobia — please allow extra time at intake and avoid clinical language in initial contact."

📝 Existing documentation: "I can forward recent OPG and medical summary on request."

Consent confirmation

By submitting this form, you confirm that you have obtained the patient's (or their guardian's) verbal or written consent to share their information with Continuum Teletherapy & Allied Health for the purpose of coordinating care.
Consent confirmation