Referral Forms for Assistive Technology Appointments

We know that your time is valuable. It is therefore recommended that you complete one of the Assistive Technology Appointment Referral Forms when booking an appointment. This information will allow our team to prepare for your appointment and ensure the relevant equipment is available.
Once completed please email the referral form to or fax to (08) 9381 0611

Please choose one of the follow appointment forms, either the general, the wheelchair or the specialised equipment forms listed below:

General Forms
Referral Form General (DOCX, 301 KB)

Wheelchair Forms

Specialised Equipment Forms

If you need the form in an alternative format or have any difficulty completing it, please contact us on the Enquiry Line (Occupational Therapist or Speech Pathologist)
Telephone: (08) 9381 0608
Toll Free: 1300 885 886 – Local call from WA
Skype: ilcwahelp
Fax: (08) 9381 0611