NDIS Referral

Participant NDIS number

Current NDIS plan dates

IMPORTANT: Please attach copy of Participant’s current NDIS Plan and other relevant reports (or email as soon as practicable).

Start Date

Finish Date

Title

Date of Birth

First Name

Last Name

Address

Suburb

Post Code

Mobile

Email

Preferred method of contact

Phone

Email

SMS

Name

Relationship to participant

Contact number

Email

How is your NDIS fund managed?

Plan managed

Self-managed

Agency Managed

Name of Plan Manager

Plan manager telephone

Plan manager contact email

Does the Participant use a Support Coordinator?

Yes

No

Name of Support Coordinator

Support Coordinator company

Support Coordinator telephone

Email of Support Coordinator

Who is the preferred primary contact?

Participant

Next of kin/ Legal Guardian provided

Support Coordinator

Translator/ interpreter required?

Yes

No

Preferred language

Please provide further details regarding translator or interpreter needs below, including language, dialect, non-verbal or sign details

Is this a self-referral?

Yes

No

Date of referral

Referrer Name

Referrer Organisation

Please add further details about your disability below

How would you like us to assist you? Please select the service(s) you require. Should you require an alternate service, or a slightly modified service, please complete further information below.

Further information

What would you like to achieve from your OT referral?

Any additional information

If the service is via telehealth, you do not need to complete this checklist.

Please complete accurately to ensure the safety of our therapists entering the home of the Participant.

Will other people be present when the OT visits?

Yes

No

Please provide further details about who will be in attendance and their relationship to the participant.

Is there accessible car parking and property access?

Yes

No

Is there mobile phone coverage?

Yes

No

Are pets present? (If present, pets need to be restrained at time of visit)

Yes

No

Does anyone at the property (including anyone present during the assessment) have a history of being aggressive/ violent?

Yes

No

Please provide further details including nature of incident, date of most recent incident

Does anyone at the property have a history of alcohol or illicit drug dependence?

Yes

No

Does anyone at the property have an infectious disease and/ or contagious illness?

Yes

No

Please provide further information

Are there any other factors relating to the home or tenants that may be relevant to the safety of our therapists entering the property?

Yes

No

Please provide further information

NDISReferral

Appointment Booking Form

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