Referral Participant Details Participant Name : D.O.B: Gender: MaleFemaleOther NDIS Number : Contact details(Home) : Contact details(Mobile) : Email address : Language spoken at home : Interpreter required : YesNo Preferred option for communication : EmailPostPhone Do you identify as Aboriginal and Torres Strait Islander? YesNo Residential Address: Postal Address (if different from above) : Is there a Guardianship and/or Administration order in place? YesNo Is there a Behaviour Management Plan in place? YesNo * Participants under the age of 18, under guardianship or in the care of family or caregivers, please complete below Name of Parent/Guardian 1: Primary Carer YesNo Lives with Participant YesNo Emergency Contact YesNo Relationship to participant ParentGuardianCaregiverOther Email address Contact details(Home) : Contact details(Mobile) : Residential Address: Postal Address (if different from above) : Name of Parent/Guardian 2: Primary Carer YesNo Lives with Participant YesNo Emergency Contact YesNo Relationship to participant ParentGuardianCaregiverOther Email address Contact details(Home) : Contact details(Mobile) : Residential Address: Postal Address (if different from above) : Disability / Medical Conditions including any diagnosis if relevant. Medication/s Required Medication Assessment Tool Strategies Developed Identified in Support Plan Medication Plan and Consent Form YesNo YesNo Medication – Self Medication Assessment YesNo YesNo Medication Risk Indemnity Form YesNo YesNo Behaviour Support Behaviour Support Plan documents collected for authorisation purposes (if relevant) YesNo Behaviour Support Plan available on NDIS portal? YesNo * Other service providers currently using (include Specialist Behaviour Support Provider, if relevant) Name : Phone number : Email : Frequency of use: Address: Name : Phone number : Email : Frequency of use: Address: Health Care Information Medicare Number : Expiry Date : Reference Number : Private Healthcare Provider : Membership Number : Reference Number: : Doctor Name : Phone Number : Address : Funding NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants) Phone Number : NDIS Date: Self-ManagedPlan Managed Please provide details for invoices Name: Email : Comments : Preferences Preferred name Religious Requirements Cultural Requirements Communication device Physical Assistance Other Considerations Goals and Aspirations What do you want to achieve for yourself – life skills, physically, socially etc? Immediately In 6 months Next year Risk Assessment Risk Assessment Tool Strategies Developed Identified in Support Plan Individual Risk Assessment Profile YesNo YesNo Safety Environment Checklist – Home YesNo YesNo Participant Safe Environment Risk Assessment YesNo YesNo Nutrition and Swallowing Risk Checklist YesNo YesNo I understand that: This organisation owns these records. Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties I can ask to see records and receive a copy Records are archived for a set period according to policy and procedure I understand that all information obtained will be kept confidential.
