Translation

Menu name

1800 362 278

Main menu

Home
About Us
NDIS Services
Accommodation
- Supported Independent Living (SIL)
- Respite (STA & MTA)
NDIS Info

Main menu

Referrals

Intake Form
Referrals Form
Complaints / Providing Feedback
Client Satisfaction Survey

Referral Form

It's simple to refer to D&AC Services. Just complete the form below and our friendly team will get in contact with you.

Are you submitting this referral for yourself?

1. Is there a Positive Behaviour Support Plan (PBSP) in place or under development?

If yes, what kind of PBSP?

Interim Comprehensive Not Sure

Does the PBSP include restrictive practices? *

Yes No Not Sure

2. Is there an authorisation in place for use of restrictive practices?

3. Are there any known behaviour/s of concern?

a. What are the behaviour/s?

b. How often does the behaviour/s occur?

c. How is/are the behaviour/s managed / what is the normal intervention?

4. Does the person have a diagnosed mental health condition?

If yes, please specify:

5. Is some or all the funding in your NDIS plan managed by the National Disability Insurance Agency (NDIA)?

If yes, please specify:

6. Does your NDIS plan require that one or more items of support must be provided by a registered NDIS provider?

If yes, please specify:

Do you have consent from the person that you are referring or their representative to share the information in this form?

Yes

Referrer Details

Referrers First Name

Referrers Email

Referrers Last Name

Referrers Phone

Referee's Organisation / Other

Who is the Referrer?

If other, please specify

What Services are you Interested in?

Other services you're interested in?

Core Support Services

Support Coordination

Plan Manager

Social & Community Participation

Accomodation

Allied Health

Participant / Client Details

This is for the person who is being referred.

NDIS Number

Client First Name

Mobile

NDIS Plan Start Date

Client Last Name

Telephone

NDIS Plan Finish Date

Date of Birth

Client Address

City

ZIP/Postal Code

State/Province

Country

Gender

Male Female Other

If other, please specify

Do you identify as Aboriginal and Torres Strait Islander?

Yes No

Preferred option for communication

Post

Phone

Are you from a Cultural and Linguistically Diverse (CALD) Background?

Yes No

Language spoken at home

Interpreter Required

Yes No

Disability/Medical Conditions including any diagnosis if relevant

Any additional information, brief or comments

Funding

NDIS Information

Is the client a participant of the National Disability Insurance Scheme?

Yes

Unsure

NDIS Funding Status

A copy of the NDIS plan MUST BE provided, so that a service agreement can be generated.

NDIS Managed

Self-Managed

Plan-Managed

NOTE: A copy of the NDIS plan MUST BE provided, so that a service agreement can be generated.

Organisation / Providers Name

Contact Person

Address

Phone (Business Hours)

Alternative Contact Person

Website Address

Mobile

Comments

Consent

I understand that these records are owned by this organisation

I understand that information withese these records wll be shared with other staff within the organisation on and only when staff require the information to carry out their duties

I understand that I can ask to see records and receive a copy

I understand that records are archived for a set period according to policy and procedure

I understand that all information obtained will be kept confidential

Relevant Documents

Please Attach NDIS Plan, Allied Health Reports, and any other documents
NOTE: Please upload one document per "Upload File" Button.

I give consent to share my client's or participant's information with relevant stakeholders

Yes

I agree to have my details saved

Email address

ACKNOWLEDGEMENT OF COUNTRY

D&AC SERVICES ACKNOWLEDGES AND RECOGNIZES THE TRADITIONAL OWNERS OF THE LAND UPON WHICH WE LIVE AND WORK, AND WE PAY OUR RESPECTS TO THEIR ELDERS BOTH PAST, PRESENT AND FUTURE.

OUR VETERANS