LifeChoice Referrals Participant InformationFirst Name *Last NameD.O.B *Region *Hervey BayMaryboroughOtherGender *FemaleMaleUndisclosedOther RegionIf your region is not listed please specify it here.Type of Funding *NDISDVAPrivateOtherReferred By *NDIS LACSupport CoordinatorGuardian/ NDIS NomineeSelfOtherFunding Source *If your funding source differs to those listed, please fill it in here.Other ReferralWho referred you to LifeChoice?Contact number of referrer *Referrer email addressPlease list any known disability diagnosesDoes the participant have behaviours of concern? *NoYesSupports required by Life ChoiceSupports required by Life Choice *Support ServicesAllied HealthSupport CoordinationParticipant SupportType of Support required *SIL - Supported independent LivingADL – Assistance with Daily LivingCommunity Access/ Social ParticipationEmployment Support(Non-SIL) Approx. hours per week support required *5 or under10 or under15 or under20 or under30 or over(Non-SIL) Preferred Times for support *6:00AM - 9:00AM9:00AM - 12:00PM12:00PM - 3:00PM3:00PM - 6:00PM6:00PM - 9:00PMAfter 9PMAny specific support staffing preferences/ requirements, or comments?Allied HealthType of clinician required *Occupational TherapyPhysiotherapy/ Exercise PhysiotherapySpeech TherapistPsychology/ Counselling/ Social WorkType of support required: *Functional AssessmentAssistive Technology AssessmentHome ModificationsOngoing TherapyHow soon do you require supports to commence? *UrgentWithin 1 monthWithin 2-3 monthsOver 3 monthsAny specific clinical staffing preferences/ requirements, or comments?Support CoordinationWhat is your current Support Coordination situation? *No current Support Coordinator – looking for first timeNo current Support Coordinator – have left past Support CoordinatorHave current Support Coordinator – wanting to transfer to Life Choice as new providerAny specific support coordinator preferences/ requirements, or comments? Send Message
