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Occupational Therapy Driving Assessment

Occupational Therapy Driving Assessment referral.

Simply fill in the relevant form below, and we'll be in touch as soon as possible.

Occupational Therapy Driving Assessment Referral

Full name

Date of birth

Gender Identity

Address

Suburb

Postcode

State

Phone number

Email

Language/s spoken

Interpreter required?

Yes

No

Is client best person to contact?

If best contact different to client, list contact details

Diagnosis

Date of injury

Reason for referral

Fitness to drive for acquired disabilities, medical conditions or aged-related changes

Learner driver

Vehicle modifications

Work-related drivers

Other

List of medications (including dosage)

Select impairments from list below

Vision

Motor

Sensation

Perception

Cognition

Behaviour

Communication

Or Medical Summary attached

Funding stream

Current drivers licence or learners permit number

Driver's licence or learner's permit

Classes

Expiry date

Type of vehicle

Manual

Automatic

Make and model

GP/treating specialist

Practice name

Practice address

Phone number

Email

Further comments

If client has a medical condition or disability that has the potential to impact on clients ability to drive, they are required to report this to the Department of Transport and be assessed by the relevant health professional, their doctor or specialist. Has mandatory reporting been completed by themselves or on their behalf?

Yes

No

Referrer name and designation (must be GP or treating specialist)

Opt-In

By checking, I agree I am the referrer stated above.

Completion by any other person other than the referrer is fraudulent and a criminal act. In Western Australia, fraud is considered an offence and is recognised under Section 409 of the Criminal Code Act Compilation Act 1913 (WA).

Thank you for contacting us.
We will get back to you as soon as possible.

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Or Alternatively, download and electronically complete the Kemp Allied Health OT Driving Assessment Referral and Medical Clearance form.

Send a referral online

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Kemp Allied Health acknowledges the Traditional Owners of Country throughout Australia and pay our respects to Elders past and present.

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