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NDIS Referral Form

If you are human, leave this field blank.

Date of Referral

Participant Details

Name of NDIS Participant

Gender *

Male

Female

Non-Binary

Prefer not to say

Does the participant identify as Indigenous or Torres Strait Islander?

Yes

No

Other

Address *

Address type *

House

Apartment

Other

DOB *

Contact Number

Email

Primary contact *

Relationship to participant

Primary contact number *

Primary contact email

Interpreter required

Yes

No

Primary Language

Potential risks/safety concerns at the home (Are there any of the following safety concerns at the Participant’s home?) *

Pets

Other residents/residents with behaviours of concern

Stairs

Hoarding/issues with cleanliness of the home

Weapons

Smoker

Illicit drug user

None

Unsure: please contact Primary contact

Behaviours of concern: (Does the participant exhibit any of the following behaviours?) *

Verbal aggression

Physical aggression

Mental health concerns including self-harm or suicide ideation

Known behaviours that consultant should be aware of

None

Unsure: please contact Primary contact

Plan Details

NDIS Participant Number *

NDIS approved diagnosis *

Any other disabilities or medical conditions the consultant should be aware of:

NDIS Plan Dates *

Plan Management *

NDIA managed

Self-managed

Plan-managed

Invoice to be emailed to *

Please attached current NDIS Plan or goals if available

Referral Information

Current Concerns / Reason for Referral:

(e.g. Mobility, Communication, Functional Capacity, Life Skills etc.)

Referral for (tick all that apply) *

AT Assessment

Hydrotherapy Services (Canberra only)

Exercise Physiology (Canberra only)

SDA

SIL

Occupational Therapy – Complex Functional Assessment

Occupational Therapy – Ongoing Therapy

Other

Is there a preferred consultant for the assessment?

Referrer Information

Name of Referrer

Role/Relationship to participant

Contact Number

Email

Is the participant engaged with the Public Trustee and Guardian? *

Yes

No

Service Booking & Agreement Requirements

If yes, please provide the name, phone number and email address of the Public Trustee and Guardian.

A member of The Rehabilitation Specialists team will be in touch with you within five days to discuss your referral and triage the participant.

Please be advised that if we are not notified of a cancellation within 24 hours of a scheduled appointment, we may have to charge a full cancellation fee in order to cover the consultant’s time. Checking the box below and completing this referral confirms *

Agree

Disagree

Captcha *

reCAPTCHA is required.

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The Rehabilitation Specialists

WE CARE, WE CAN

Home
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Copyright by The Rehabilitation Specialists. All rights reserved.

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CONTACT US
SERVICES
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