Personal Injury / Rehabilitation Support Form

SchemeWise requires certain information about the injured person and referrer, as well as the relevant scheme details (unless service is sought on a private basis), in order to engage our services. We must be able to verify customer and referrer details (and funds availability) to provide service. Please work with us and be clear about the circumstances in a matter - likewise we will do our best to support rehabilitation and recovery but must also reserve a right to refuse to advance a service if we think it may cause harm or not offer benefit (e.g. low service approval may inhibit a positive outcome being attained).

NOTE: Referrers should reach out to us on 1300 785 567 or via email and discuss a potential service firstly, as 'unannounced' service requests will NOT be actioned or responded.

All injury-related services may be required to provide at least a progress report, and relevant scheme/therapy goals are required for this purpose. SchemeWise will secondarily use same in service planning and monitoring. We use S.M.A.R.T goal setting. Our counselling services, deliver along a solution-focused approach, are trauma informed, and may also utilise other psychotherapies as required within a person's circumstances.

Please look over the information SchemeWise requires (below) and ensure that all the information is available to you BEFORE you start - we've tried to ensure our service needs are simple and straight forward, while also making it as convenient for you as possible. Some information is essential for us to put in place a service agreement/service contract, without which, there will be additional delays. Fields marked 'required' must be populated with information, or this form will NOT allow you to submit.

Thanks for your referral to SchemeWise.

Customer's First and Last Name (required)

Customer's Address (required)
[address* cust-add1]

Customer's Email (required)

Customer's Phone/Mobile (required)

Customer's date of birth (required)

First and Last Name of Referrer (required)

Role of this person (required)
Scheme Case ManagerMedical / Allied-health ProviderSelf ReferralCommunity Service AgencySpouse/Family MemberInsurance ProviderScheme Provider

Referrer Email (required)

Referrer Phone/Mobile (required)

Service required (ONLY CHOOSE ONE)
Case ManagementNursing SupportNurse Assessment - RehabCounselling ServiceEmployment CounsellingOccupational TherapyPhysiotherapyInjury Management AssessmentWork Role Assessment

Source funds for this service are expected from
Funds sourceACT Lifetime CareNSW Lifetime CareNSW iCareComcareOther insurance schemePrivate

Frequency of service being requested (if known / relevant e.g. weekly, fortnightly, some other period?)

Relevant Scheme Reference / Claim Number (required)

Customer's Injury Information - please include date of injury (required)

Customer's Recovery Goals (required)

Customer's work status (Only choose one)
Working - Full capacityWorking - part capacityNot Working - full capacityNot working - part capacityNot working - No capacityCapacity not assessed / unknown

Detail how the funds for this service will be claimed? (required)

Customer's case manager name (leave blank if same as referrer or not relevant)

Customer's case manager organisation (leave blank if not relevant)

Customer's case manager work address incl. suburb, state/territory & postcode (leave blank if unknown)

Case Manager Phone/Mobile (must provide if used - leave blank otherwise)

Case Manager's Email Address (if different to above or leave blank if not relevant)

What is the Email Address to send invoices too (must provide)

Person's medical practitioner details (if known, please provide treating doctor's name, practice name, address and contact details)?

Disability/Injury Diagnosis and/or brief background information on why the service is sought (if known, to assist service design)?

Are there any risks we need to know about in providing this service? (e.g. short-term memory issues, mobility problems, behaviours like anger/aggression, vaccination status or other risks/precautions, etc)

Customer's Employer Name (if relevant)

Customer's Employer Street Address (if relevant)

Employer Representative / HR Name (first and last name please)

Employer Representative Email (if relevant)

Employer Representative Phone/Mobile (if relevant)

File Uploads (please provide relevant documents to assist us)

Consent and Privacy Statement: By clicking the 'Submit Service Request' button below you are agreeing to provide this information to SchemeWise and you also agree we may hold this information on our systems for the purposes of discussing and advising about the service and our othrer services we think may be of interest. You also agree you have discussed and obtained agreement from the nominated customer to make this request and/or that they are aware of the request for service being made. We take privacy seriously. For your assurance, the information provided is held internally in the strictest confidence/privacy and is not sold, provided or disclosed to any other party.