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Indigo Occupational Therapy Driver Assessment

Self Referral Form: Learner Drivers

Indigo provides Occupational Therapy Driver Assessments.

Customers can self-refer into the service if they have a valid learner permit from the Department of Transport. A copy of the learners permit front and back is required to complete a self-referral form.

Please contact the Department of Transport directly to apply for a learner’s permit. A computer-based theory test needs to be completed and the Department of Transport may seek further clarification regarding your current medical conditions.

Please note that the Department of Transport (DoT) Mandatory Reporting of Medical Conditions requires all drivers report any permanent or long-term medical condition or disability that may impair their ability to drive. For more information: https://www.transport.wa.gov.au/licensing/report-a-medical-condition.asp

If you are unable to obtain a learner’s permit due to medical concerns, a referral from a health professional is required to proceed with an assessment.

Assessments are conducted by a Driver Trained Occupational Therapist and include a clinical off-road assessment and practical on road driving assessment completed with a driving instructor experienced in rehabilitation.

FEES are payable for OT Driver Assessment

Individuals may be eligible for the below funding or subsidies to assist with fees, depending on their eligibility:

Private Health Insurance (ancillary billing codes H100 and A022).
National Disability Insurance Scheme (NDIS) Indigo is a registered provider, participants must check their eligibility for NDIS prior to being considered for alternative funding.

Please complete all the relevant funding information on the below form, as this will enable our staff to set everything up in a timely manner.

HOW TO SELF REFER:
COMPLETE ALL SECTIONS OF REFERRAL FORM AND ATTACH A COPY OF YOUR CURRENT LEARNERS PERMIT.

CONSENT TO COLLECT and RELEASE INFORMATION

This consent will remain current for 12 months and can be withdrawn at any time.

Collection and Privacy Statement

We collect your information for the primary purpose of providing a Driving Assessment and Lessons.
With you consent, your details will be added to our client management system and will only be
accessed for the purpose for which they were collected and by those involved in providing your service.
You may choose someone to liaise with us on your behalf by providing their contact details.
We will only share your information with health practitioners, funders, other government departments
or relevant parties as part of providing your service. You can withdraw or amend your consent
at any time and can request to access and seek correction of the information which
Indigo holds about you.

For further information, you may access our Privacy Policy on the Indigo Website or by contacting
our Driver Assessment Team.

Occupational Driving Assessment 
The occupational therapy driver assessment I am to undertake will consist of a clinical and on road assessment to assess my ability to drive a vehicle. If required, I will undertake a vision check with an Optometrist or Ophthalmologist to check basic vision standards for driving. 

The clinical assessment will be completed prior to the on-road assessment and will consist of: 
  1. an interview to obtain information regarding my medical and driving history;
  2. a physical and sensory screen; and
  3. a cognitive and perceptual screen.
The on-road assessment will consist of: 
  • A drive through a predetermined route in a dual controlled vehicle. 
  • A qualified driving instructor will be seated in the front passenger’s seat. 
  • The occupational therapist will document the situations occurring throughout the drive. 
Following the assessment process, the occupational therapist will collate the information and complete a report to be sent to relevant parties.

Consent

I give consent for the Indigo Australasia Inc (Indigo) to electronically store my information and share my information to external sources as relevant to the delivery of my services.

Referral Details

Customer's Details

Salutation

Other Contact - Carer / Family

General Practitioner (GP)

Reason for Referral

Current Learners Permit

Please upload a copy of the permit, e.g.. .pdf or .jpeg

Current Vehicle

Medical Information

Exact date if known, month & year

Optional - use if not enough space provided above

Funding Information

 

NDIS Participant

NDIS Plan Attached
How is Capacity Building managed in your plan?
Thank you for completing this form, a representative from Indigo will contact either yourself or your primary contact to proceed with your assessment.