Participant First Name

Participant Last Name

D.O.B

Age

Gender Gender MaleFemaleOther

Do you identify as Do you identify asAboriginalTorres Strait IslanderOtherNone

Email Address

Contact Number

Address

Primary Diagnosis

Funding Source Funding SourceNDISSTRCSelf FundedThird Party

NDIS/STRC/REF NUMBER

Plan/Package Dates (start & finish)

How is your NDIS Plan Managed How is your NDIS Plan Managed Plan Managed NDIA Managed Self Managed

Are you able to provide copies of your plan and relevant documents? Are you able to provide copies of your plan and relevant documents? Yes - NDIS Plan or Goals Yes - Other Documentation (e.g. previous reports from allied health/medical summaries where possible)

Contacts

Primary Contact Full Name

Primary Contact Relationship to Participant

Primary Contact Email Address

Primary Contact Phone

Secondary Contact Full Name

Secondary Contact Relationship to Participant

Secondary Contact Email Address

Secondary Contact Phone

Support Coordinator

Support Coordinator Name

Support Coordinator Company

Support Coordinator Email

Support Coordinator Phone

Plan Manager

Plan Manager Name

Plan Manager Company

Plan Manager Email

Plan Manager Phone

Service Agreements to be sent to Service Agreements to be sent to Participant Primary Contact Support Coordinator OPG Other

Appointments to be made with: Appointments to be made with: Participant Primary Contact Support Coordinator OPG Other

Invoices to be sent to: Invoices to be sent to: Participant Primary Contact Support Coordinator OPG Other

Service/s being Requested

Positive Behaviour Support Plan Positive Behaviour Support Plan Capacity Building Improved Relationships funding is required for comprehensive positive behaviour support plans

Counselling Counselling Initial assessment Ongoing therapy

Dietitian Dietitian Initial assessment Ongoing therapy Nutrition and diet analysis Meal plan development Ongoing paediatric feeding therapy Cooking and/or shopping education

Exercise Physiology Exercise Physiology Assessment (please specify below ) Ongoing therapy

Assessment - Please Specify

Occupational Therapy Occupational Therapy Assessment and recommendation Ongoing therapy Assistive technology Home modifications assessment Functional capacity assessment

Psychology Psychology Initial assessment Ongoing therapy Functional Capacity Assessment Diagnostic (DSM-5) Exploring Housing Options

Social Worker Social Worker Family dynamic complexity Navigating systems (e.g. legal, health, housing) Change in circumstances (e.g. end of life plan, health directive, QCAT application) Individual planning and linking into relevant services Counselling Advocacy

Physiotherapy Physiotherapy Initial assessment Ongoing therapy Assistive technology assessment Hydrotherapy initial assessment

Speech Therapy Speech Therapy Formal assessment (no assessment previously completed in the past 12 months) Ongoing therapy AAC assessment/trial/intervention Swallow/mealtime assessment ADOS Assessment

If unsure you will be offered a Discovery Meeting with our Clinical Team Leader If unsure you will be offered a Discovery Meeting with our Clinical Team Leader Unsure

Assessment/Reports Required Assessment/Reports Required Yes No

Yes (please specify type)

Date required

Additional comments

Funding Confirmation

Available Capacity Building – Improved Daily Living Budget

OR Maximum funding/hours for service/s requested

If unsure 5hrs of funding will be allocated to your account, this will enable us to commence services. Further funding requirements will be discussed at your initial consultation.

Appointment Information

Appointment Location Appointment Location Life Choice Office Home* (risk assessment required) Pool School/Preschool/Kindergarten**

If school/kindy visit required please provide name of facility

* Please note that Home/School/Kindy/Pool appointments will incur additional travel costs

** It is the responsibility of the parent/guardian to coordinate with the facility regarding any necessary paperwork and appointment times

Additional Comments

Please provide any other relevant information

Referral Completed By

Name

Relationship

Date