NDIS Referral

20%

Participant Name

First Name *

Last Name

Participant Gender *

Male

Female

Other

Participant Date of Birth *

Participant Phone

Participant Email

Participant Address

Address 1 *

Suburb

Post Code

State

Living Arrangement *

Living Independently

Living with Family/Partner

Homeless

Other

Participant NDIS Number *

How is your plan managed? *

Self-Managed

Plan-Managed

NDIS Managed

Plan Start Date

Plan End Date

Plan Manager Name

First Name *

Plan Manager Email

Plan Manager Phone

What is the participants primary diagnosis? *

Developmental Delay

Psycho-social

Austism

Intellectual Disability

Sensory

Physical

Neurological

Cognitive/Acquired Brain Injury

Other

Please Specify

Clinician Required: *

Physiotherapist

Exercise Physiologist

Occupational Therapist

Podiatry

Type of service required: *

Functional Capacity Assessment

Assistive Technology

Home Modification

Support documentation

Clinic Based Services (Norwood)

Home Based Services

Ongoing Capacity Building Services

Paediatric Services

Hydrotherapy

Other

Reason for Referral: *

In your own words please state the reason for your referral:

Desired Outcome: *

In your own words please state the outcome you require from our services.

Will the services be ongoing or a once off? *

Ongoing

Once off

Where are you requesting services? *

Flex Clinic (Norwood)

At residence

Other:

Flex Clinic (Kadina)

Specify provide further information regarding the location for services : *

Are you the NDIS Participant making the referral today? *

I am the NDIS Participant

I am referring on behalf of the NDIS Participant

First Name *

Last Name *

Referrers Phone Number *

Referrers Email *

Please state your relationship to the NDIS Participant *

Support Coordinator

Local Area Coordinator

Case Manager

Family Member / Carer

Plan Manager

Other

Please specify: *

Who is the primary contact to book the first appointment? *

Participant

Support Coordinator

Local Area Coordinator

Family Member / Carer

Plan Manager

Other Service Provider

Other

First Name *

Last Name

Phone *

In order for this referral to be completed please provide information regarding any safety concerns.

Does the participant have any behaviours of concern? *

Yes

Unsure

Please specify *

Does the client have a positive behavioural support plan? *

If 'Yes" please upload in the next section

Yes

Unsure

Are there any pets at the participants residence? *

Yes

Unsure

Please specify *

Please provide information regarding the type of pets on the property and if there is any safety concerns for our staff.

Has anyone at the residence been known to be aggressive/violent? *

Yes

Unsure

Please specify *

Does anyone at the residence have a criminal history? *

Yes

Unsure

Please specify *

Does the client have a history of substance abuse? *

Illicit drugs and/or alcohol

Yes

Unsure

Please Specify *

Are you aware of any firearms being stored at the property? *

Yes

Unsure

Please Specify *

Will anyone else be present during the appointment? *

Yes

Unsure

Who will be attending? *

Does any of the residence have any health concerns? *

ie cold/flu symptoms / COVID / gastro / infections diseases

Yes

Unsure

Please specify *

Are there any environmental risks we need to be aware of? *

Please specify if there are any environmental risks and/or if there is adequate space in the home.

Yes

Unsure

Please Specify *

Are there any communication needs we need to be aware of? *

ie will a interpreter be required, is English a second language, is the participant non-verbal

Yes

Unsure

Please Specify *

Form Upload

Please upload any supporting documentation/previous reports to assist with information gathering. This will support us to be prepared for our initial appointment and support us to allocate to the most appropriate therapist.

How did you hear about Flex Care? *

Flex Staff Member

Google

Other Provider

Facebook

Instagram

Networking Event

Word of mouth

Family Member

Support Coordinator

Local Area Coordinator

Other

Please Specify *