ILC Tech Referral – Mounting

Thank you for providing the following information. This general information will allow our team to prepare for your appointment and ensure the relevant equipment is available.
Client Information
First Name*: / Last Name*:
Date of Birth*: / Age
Suburb*: / Street Address:
Phone Number*: / Email:
Country of Birth: / Main Language Spoken:
Funding / Eligibility (tick or circle all applicable):
Disability Support Pension / Aged Care Pension / Health Care Card / DVA Card
NDIS / WANDIS / Better Start / Helping Children with Autism / Enhanced Primary Care
Home and Community Care (HACC) / Commonwealth Home Care Package /
Private Health Insurance
Other:
Primary Diagnosis:
Other Relevant Medical History:
Weight*: / Height*:
Mobility: eg. method of mobility, equipment used, level of assistance required
Transfer Ability: eg. method of transfers and level of assistance required
Communication: eg. difficulties with hearing, vision, speech, devices used, level of assistance required
Carer / Parent / Alternate Details (please circle)
First Name: / Last Name:
Relationship to client:
Phone Number: / Email:
Primary Therapist / School / Support Agency Details (please circle)
First Name: / Last Name:
Position: / Organisation:
Phone Number: / Email:
Reason for Referral
Summary of why the referral has been sent. What equipment category / type do you wish to view?
What are the difficulties the client is having? What are their strengths / abilities?
Include any relevant details relating to the person, their carers and environment.
Current Equipment Used
What relevant equipment is the client currently using? Why is this not sufficient?
1. Make and model of device(s) to be mounted. E.g. AAC device, iPad, switch
2. What is the device used for?
3. What is the client’s access method? e.g. direct touch, switch, eye gaze?
4. Make and model of wheelchair. Please include any photos of the client in the chair if available?
5. Is seating system likely to change in the next six months?
Yes No
6. Does the client use tilt-in-space features of their wheelchair?
Yes No
7. Does the client self-propel or drive wheelchair?
Yes No
8. Is the client’s weight well within the maximum load capacity of the wheelchair?
Yes No
9. Is there anything else permanently or temporarily attached to the chair? If YES what are these items (e.g. tray)? *Please ensure these are brought along to the appointment.
Yes No
10. Does the client have any unintentional movements or positions likely to affect the position of the device mounted to the chair? e.g. leaning out of the chair. If YES what are these?
Yes No
11. Are there narrow doorways or tight corners in the client’s environment that will affect where the device is mounted?
Yes No
12. How does the client transfer in/out of the wheelchair?
13. Is the wheelchair ever folded or dismantled for transport?
Yes No
14. Will the wheelchair be transported in a vehicle?
Yes No
15. Does the mounting system need to hold the device in more than one position? If YES, please specify positions.
Yes No
16. Does the user need to be able to move the mount independently?
Yes No
17. From which side are caring activities carried out?
Left Right
18. Does the device need to be used elsewhere? e.g. bed or alternative seating system
Additional Appointment Requests:
Preferred date / day / time*:
Who will be attending appointment?:
Referrer Details
First Name*: / Last Name*:
Relationship to client*: / Best contact*
Date of Referral*:

Page 1 of 3