Referral
Referral form for MS Plus Support and Services
Contact us form - MS Plus Services and Support
Health professional details (referrer)
Are you a MS Clinic?
MS Clinic Name
If not, what’s your organisation’s name?
Job title
Please select...
Neurologist
Nurse
Support Coordinator
Allied Health Professional
GP
Rehabilitation Consultant
Other...
Other job title
First Name
Last Name
Phone number
(office number, mobile)
Email address
I have my patient's* consent to provide their personal information to MS Plus for the purpose of support and services.
My patient is an NDIS Participant
* = this includes consent from the patient's guardian if they are not able to provide consent themselves.
Who the service is for
First Name
Last Name
Phone number
(mobile or home no.)
Email
Date of Birth
Residential Street
Residential Suburb
Residential state
Please select...
ACT
NSW
TAS
VIC
(ACT, VIC, NSW, & TAS only)
Residential Postcode
Clinical assessment
Medical history & treatment
(inc. date of diagnosis, medication prescribed, name of specialist, etc)
Symptoms
Home & social situation
(e.g. availability of carers, support network, etc)
Attach documents (optional)
(e.g. pertinent medical documentation, letters from Centrelink, etc)
Services/Programs desired
I am referring my patient for:
Allied health services
Plus Balance
Plus Boxing
Plus Continence
Plus Diet and nutrition
Plus Exercise physiology
Plus Hydro
Plus Occupation Therapy
Plus Physiotherapy
Plus Pilates
Plus Flex and Flow
Accommodation
Plus Respite
Plus Residential
NDIS services
Plus Support Coordination
Plus Plan Management
Employment services
Plus Employment Support
Information and wellbeing services
Information/Education
MS Nurse Advisor
Peer Support
Note:
not all services are available in all states; however we will endeavour to refer on to other providers where appropriate.
Reason for referral and expected outcome
(e.g. "client wants to return to work", "immunotherapy information", etc)
Should MS contact the patient directly?
Yes
No
If we call the patient and need to leave a message, can we say we are calling from MS?
Yes
No
Who should we contact to arrange appointments?
(inc. full name, contact no., relationship to patient - e.g. carer)
Does your patient require an interpreter?
Yes
No
What language does your patient speak?
Does this patient have a primary carer?
Yes
No
Carer's details
(carer's full name, contact number, relationship to patient, etc)
Note: Depending on where you live, we can visit you in your home, see you face-to-face in one of our gyms, or via telehealth.
Tell us more about how we can help you:
Account Id
Contact Information