NDIS Referral Form

Your details (Participant)

Name*

First name Last name

Preferred name

Email*

Date of birth*

Address*

Street Address Address Line 2 Suburb/City/Town State Postcode Country

Phone number*

Your gender

Your cultural identity

What is your preferred method of contact?*

Phone

Text

What is your preferred document style?*

Standard Print

Large Print

Easy Read

Your NDIS Plan

NDIS Reference Number

Do you wish to share a copy of your NDIS Plan with us?*

Yes

Your NDIS Plan*

If you have a digital or scanned copy of your NDIS Plan, please upload it here

Accepted file types: pdf, Max. file size: 10 MB.

NDIS goals*

To best support you, we would like to know what your NDIS Plan goals are

Do you know your NDIS Plan start and review dates?*

Yes

Please provide any information you can regarding your NDIS Plan start and review dates*

NDIS Plan start date*

NDIS Plan review date*

Do you require a translator?*

Yes

What language do you require?*

Do you have any health concerns?*

eg. Diabetes, Asthma, Epilepsy

Yes

Do you have a Mealtime Management Plan?*

Yes

Please give details about your health concerns*

How would you describe your disability?*

How does your disability impact your daily life?*

Do you have a Positive Behaviour Support Plan (PBSP)?*

Yes

Do you currently have a Support Coordinator or Recovery Coach who supports you with your NDIS plan?*

Yes

Unsure

Please provide the contact information

Support Requested

What support(s) are you requesting?*

Community Supports

Support Coordination

Specialist Support Coordination

Recovery Coach

Employment Supports

Other

If Other, please provide details

How many hours of support per week?*

What activities would you like support with?*

eg. shopping, appointments, job applications, on-the-job support, employment skills

Preferred days and times of support*

Monday

Tuesday

Wednesday

Thursday

Friday

Preference of worker

Female

Male

No preference

Please provide the amount of funds you are able to spend on the requested UnitingSA supports*

Budget management

Plan Manager details*

Do you have any other supports with UnitingSA?*

Yes

Are you interested in any other supports provided by UnitingSA?*

Yes

If yes, please provide details*

Contact Information

Who would you like us to contact about this referral?*

Participant, as per Step 1

Third party contact

Please provide the details of someone else we can contact if we cannot get in touch with you, or if you need someone to assist you with accessing our support, such as a relative, close friend or carer.

Name*

Relationship to you*

Email address*

Phone number*

Additional information

UnitingSA makes every effort to ensure supports are respectful of each Participant's culture, diversity, values and beliefs.

Is there any additional information you would like to share (for example, likes/dislikes, behaviours of concern)?

How did you hear about UnitingSA?

Please be advised that submitting this request is not a guarantee that services will be offered to you.