Text Size
zoom in
zoom out

Referrals

Please complete all sections of the on-line referral form if you are seeking a new assessment, re-assessment or training.

Referral

  • When we receive your referral, you will be sent a letter acknowledging the referral
  • If the referral is urgent then we will see you as soon as possible
  • Sometimes there is a wait for the assessment and we will let you know the estimated wait time

Assessment

  • You may invite other people to attend your assessment appointment with you
  • A TalkLink case manager will manage the assessment and will explain the process with you
  • We will talk about your needs and abilities with regard to communication
  • We will discuss strategies & show you potential equipment

Equipment Trial

  • Often it is a good idea to try the different equipment options to find out what works for you
  • Once the trial process is complete, then TalkLink in consultation with you and your team, will select the most cost effective equipment option for you to meet your need

The TalkLink case manager submits a funding application.

  • If the funding is approved, then the equipment is ordered and delivered to TalkLink (or directly to you). We then set up the equipment and teach you and anybody else you wish to include, on how to use the equipment

We will then review needs 3 and 12 months after you receive the equipment.


Do you need help with the referral form?

Contact us and we’ll get back to you as soon as possible.

If you would like to manually fill out the form, download the Word or PDF document

1. CLIENT DETAILS

Male
Female
Email
Phone
Mobile
Text
Letter
Other (specify)
Maori (please specify tribal affiliation)
New Zealand European
Pacific Island (please specify)
Other (please specify)
No
Yes
No
Yes
No
Yes

2. PARENT / CAREGIVER (If applicable)

3. PERSON MAKING REFERRAL (If different from 1 or 2 above (e.g. therapist))

4. ARE YOU ELIGIBLE FOR ACC ASSISTANCE IN RELATION TO THIS REFERRAL?

No (go to question 5)
Yes (please provide the following details)

5. HAVE YOU BEEN SEEN BY A NEEDS ASSESSMENT SERVICE CO-ORDINATION (NASC)?

No (go to question 6)
Yes (please provide the following details)

6. CLINICAL DIAGNOSIS/DISABILITY (Information about your disability relevant to this referral)

Please enter or attach any relevant reports.

(Max file size 2mb)

7. REASON FOR THE REFERRAL (Please tick)

a) Assessment/Consultation
b) Re-assessment (previously seen by TalkLink)
c) Training

Would you like to receive details of TalkLink courses?

No
Yes

8. WHAT WOULD YOU LIKE TO GAIN FROM THIS REFERRAL?

e.g. Support with existing equipment, implementation of a communication system, assistance to move from low tech to high tech equipment, allow access to computer etc.

9. PLEASE PROVIDE ADDITIONAL INFORMATION ABOUT YOUR CURRENT COMMUNICATION:

If this referral is for assistance with communication, please comment on language level (what can be expressed/understood), degree of speech clarity, if there is an alternative communication system in place, how much opportunity there is to communicate in a day and who with, and why the current system is not working.

10. MOBILITY / PHYSICAL / SENSORY NEEDS (including hearing and vision)

Please comment on current function, gross and fine motor movements including wheelchair use and any sensory impairment.

11. CONTACT DETAILS FOR PROFESSIONALS

Please provide details for any professionals with whom you have had recent contact.
(For example: vision or hearing specialist, physiotherapist, SENCO, teacher, psychologist, GP/specialist, neuropsychologist etc).

+ Add another professional

12. DO YOU ATTEND AN EDUCATION FACILITY OR ARE YOU IN EMPLOYMENT (PAID OR VOLUNTARY)?

No (go to question 13)
Yes (please provide the following details)

13. SAFETY

Please provide detail of any potential risks in regards to personal safety with visiting the person at home (e.g. access, dogs, medical, etc?)

14. CONSENT (to be completed by the person referred or their parent/guardian)

a) For the purposes of this assessment, I permit staff from TalkLink to obtain information from professionals or other individuals as provided above.
b) I consent to the processing of this referral.

By typing your name here you are ‘electronically signing’ this form. A copy of your email and form will be kept for our records.