NDIS referral form

NDIS Referral Form

Please complete this form to the best of your knowledge. Required sections are marked with an asterisk (*). The additional questions help us evaluate the referral and ensure that we match the person with the most suitable therapist.

What service are you after? *

Mental Health Occupational TherapyCounselling

Please note: Dietetics is not currently available

Who is making this referral? *

Where did you hear about our services

Referrer Details:

Referrer Name

Referrer Surname

Referrer Email Address

Referrer phone number

Relationship to participant (e.g. support worker, family member)

Your preferred contact methods (click all that apply):

EmailPhone CallText Message

Client Details

First Name *

Surname *

Date Of Birth *

Pronouns

Phone Number

Email

What are their preferred contact methods? (Click all that apply)

EmailPhone CallSMSPlease contact someone else

How can we best contact you? (Click all that apply)

EmailPhone CallSMSPlease contact someone else

Alternate contact person: *

Address

Diagnosis and health history (if applicable):

Next of Kin or Emergency Contact (name and phone number):

Please document any current or historical known risks (please also include risks for others residing in the same home)Risks may include the following: substance use, aggression/violence, selfharm/suicide, forensic history, etc.

Referral Details

Is this referral for assessment or therapy implementation, or both? (Click ALL that apply)

AssessmentTherapyUnknown

Please indicate what type of assessments are required or what you need the assessment for and when a report is required by (if known):

Please provide details of therapy needs (if known):

List of current supports (if applicable):

How can sessions be attended? (Select ALL that apply)

TelehealthHome visitsMeeting at another location in the community (e.g., library, park, etc.) if out of catchmentOther preference

Other preference details:

NDIS Details

NDIS Number *

NDIS Plan Start Date: *

NDIS Plan End Date *

NDIS goals (or attach NDIS plan at the end of this form)

How many hours have been budgeted for Occupational Therapy? (priced at $193.99 per hour)(Recommended 15 hours for a comprehensive Functional Capacity Assessment FCA)

How many hours have been budgeted for Dietetics? (priced at $193.99 per hour)

How many hours have been budgeted for Counselling? (priced at $193.99 per hour)

Funding allocated for counselling:

Hours budgeted for Dietetics:

Hours allocated to OT:

How are the plan funds managed?

Plan ManagedSelf Managed

Plan Manager

Plan Manager Email *

Where should we send invoices to? (Leave blank if sent directly to the participant)

Best Contacts

What email address should we send the service agreement to? (Leave blank if sent directly to the participant)(Please note we cannot commence services until the service agreement has been signed)

Who is the best person/contact to book in an appointment? (Leave blank if we should directly contact the participant)

For Assessment: We routinely gather information from sources who have a good understanding of the participant's situation. Who is the best person(s) to speak with for this purpose?

Home Visits: We need to complete a one-off Home Visit Risk Assessment for ALL new home visits. Who is the best person to complete this questionnaire? *

Additional Information

Is there any other important information or preferences that you would like to share?

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If you have any further information to provide, please feel free to email hello@coreclarity.com.au

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