CLIENT REFERRAL FORM
Adapted Physical Activity Program (APAP)
Proudly Supported by
Please return the referral form to Melinda Keynes by:
Fax: (07) 3365 6877
Email: apap@hms.uq.edu.au
Postal: ADAPTED PHYSICAL ACTIVITY PROGRAM (APAP)
School of Human Movement Studies (Building 26), University of Queensland
St Lucia QLD 4072
Enquires: Melinda Keynes 0429-579-392
Program and funding requirements
The total cost of the Adapted Physical Activity Program is $2000. This amount includes:
-
-
Initial consultation and client evaluation;
Individualised physical activity and exercise prescription (9 sessions);
Education on strategies for the adoption and maintenance of the prescribed activity
including goal setting, social support, techniques for increasing self-efficacy and self
monitoring materials;
Physical activity education and support;
Establishing links with community-based sport and recreation organisations and;
Client report including pre and post measures evaluating the programs outcomes.
Please indicate below your intended payment option:
Private Payment (this relates to
individuals who are not
receiving funding from an
organisation to complete the
program- Medicare and Private
Health Rebates may apply).
Medicare:
Medicare Number:
Card Position:
Expiry:
Funding Received (this relates
to individuals who are funded by
an organisation)
Organisation Name:
Funding Contact:
Phone Number:
Email:
Private Health Fund:
Fund Details:
Membership Number:
Card Position:
www.hms.uq.edu.au/apap
Date of Referral
/
/
Client details
SURNAME
GIVEN NAMES
TITLE
BIRTH DATE
Male
MALE/FEMALE
HOME ADDRESS
SUBURB
POSTCODE
HOME PHONE
MOBILE
EMAIL
NEXT OF KIN/CAREGIVER
_
CONTACT DETAILS
NEXT OF KIN/CAREGIVER WILL ATTEND PROGRAM TO ASSIST CLIENT
Client profile
DIAGNOSIS
DATE OF DIAGNOSIS/INJURY
COMMUNICATION
VERBAL
NON VERBAL
MOBILITY
INDEPENDENT
WALKER
TRANSFER ABILITY
INDEPENDENT
ASSISTED
TOILETING
INDEPENDENT
ASSISTANCE REQUIRED
MEMORY
NO IMPAIRMENT
IMPAIRMENT
AIDS REQUIRED, ________
HEARING
NO IMPAIRMENT
IMPAIRMENT
AIDS REQUIRED, _______
VISION
NO IMPAIRMENT
IMPAIRMENT
AIDS REQUIRED, ___________
TRANSPORT
CAR,
EPILEPSY/SEIZURE
NO
ACCESS TO A CAR
YES,
W/C
MOTOR W/C
OTHER
HOIST
PUBLIC TRANSPORT
TAXI
DATE OF MOST RECENT
/
USE AN INHALER FOR ASTHMA OR OTHER RESPIRATORY DIFFICULTIES
NO
/
.
YES
www.hms.uq.edu.au/apap
Physical activity history
RECREATIONAL/SPORTING INTERESTS
PAST/CURRENT PHYSICAL ACTIVITY HISTORY
PHYSICAL ACTIVITY GOALS
SPECIAL CONSIDERATIONS FOR ACTIVITY
PHYSICAL LIMITATIONS FOR ACTIVITY
BEHAVIOURAL LIMITATIONS FOR ACTIVITY
Medical clearance: Authority to consult medical practitioner
NAME OF MEDICAL PRACTITIONER
.
NAME OF PRACTICE
.
CONTACT PHONE NUMBER
PRIVATE HEALTH INSURANCE
No
Yes, please indicate:
Referral Details individuals who are self referring do not need to complete this section.
REFERRED BY
Self
Parent/Caregiver
Allied Health professional
Other
REFERRAL’S NAME
.
POSITION
.
PROGRAM/ORGANISATION
.
PHONE
MOBILE
.
EMAIL
.
POSTAL ADDRESS
.
SUBURB
POSTCODE
.
www.hms.uq.edu.au/apap
REFERRER’S GOALS
.
.
________________________________________________________________________________________
Privacy Statement:
The ADAPTED PHYSICAL ACTIVITY PROGRAM (APAP) complies with Australian and Queensland privacy laws and guidelines. APAP
treats information collected as confidential. Information supplied by you will only be used for the administration or educational
purposes of the University and the School of Human Movement Studies or in accordance with a specific consent given by you. The
Adapted Physical Activity Program will not make available to a third party any personal information supplied by you unless
required or permitted by law.
Client Consent:
I have read the information above and relevant information on the APAP website (www.hms.uq.edu.au/apap) and brochure. I
understand that the main aim of the APAP is to help me to become more physically active and I look forward to participating (please sign below):
I DO NOT WANT TO RECEIVE APAP PROMOTIONAL MATERIAL
SIGNATURE
DATE
/
/
.
www.hms.uq.edu.au/apap
Payment Information
Individuals funded to participate in the program
Funding Contact:
Contact Organisation:
Phone:
Email:
Fax:
By signing below I agree for my organisation to be invoiced $2000 at the conclusion of the 10 sessions.
Signed:
Date:
.
Individuals self funding their participation
While program staff will work with participants to explore funding options available it should be understood
that a payment for services will be required. The Adapted Physical Activity Program will provide an itemised
invoice for each session undertaken. This invoice can be paid via credit card over the phone (as per the
details provided on the invoice) or in person at the School of Human Movement Studies at the University of
Queensland.
Alternatively, with your permission the Adapted Physical Activity Program can charge your card after each
session. Upon the conclusion of the program, records of your card details will be destroyed. You will be
provided with a copy of the EFTPOS receipt.
I would like to pay for the program sessions using the following method:
Paying via credit card over the phone
Paying in person at the School of Human Movement Studies
Having my credit card debited by the Adapted Physical Activity Program
Card details:
Card Type:
Card Number:
Expiry Date:
CCV Number:
By signing below I authorise the Adapted Physical Activity Program to charge the session fee to my credit
card after the conclusion of each session. I acknowledge that I will receive a copy of the EFTPOS Transaction
slip and an itemised receipt.
Signed:
Date:
.
www.hms.uq.edu.au/apap