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Referral for NDIS
Support Services

Home » NDIS » NDIS Services » NDIS Referral Form

NDIS Referral Form

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Your details (Participant)

Name*
Date of birth*
Address*
What is your preferred method of contact?*
What is your preferred document style?*

Your NDIS Plan

Do you wish to share a copy of your NDIS Plan with us?*
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If you have a digital or scanned copy of your NDIS Plan, please upload it here
Accepted file types: pdf, jpg, gif, png, Max. file size: 30 MB.
If you have a digital or scanned copy of your NDIS Plan, please upload files here
Drop files here or
Accepted file types: pdf, jpg, gif, png, Max. file size: 30 MB.
    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?*
    NDIS Plan start date*
    NDIS Plan review date*
    Have you received your Impairment Notice?*
    This is confirmation of the type of disability you have received NDIS funding for
    Do you require a translator?*
    Do you have any health concerns?*
    eg. Diabetes, Asthma, Epilepsy
    Do you have a Mealtime Management Plan?*
    Do you have a Positive Behaviour Support Plan (PBSP)?*
    Do you currently have a Support Coordinator or Recovery Coach who supports you with your NDIS plan?*

    Support Requested

    What support(s) are you requesting?*
    eg. shopping, appointments, job applications, on-the-job support, employment skills
    Preferred days and times of support*
    Monday
    Tuesday
    Wednesday
    Thursday
    Friday
    Saturday
    Sunday
     
    Preference of worker
    Do you have any other supports with UnitingSA?*
    Are you interested in any other supports provided by UnitingSA?*

    Contact Information

    Who would you like us to contact about this referral?*
    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.
    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)?
    Do you have any additional documents relating to your referral that you would like to share?*
    Drop files here or
    Accepted file types: pdf, jpg, gif, png, Max. file size: 30 MB.
      Please be advised that submitting this request is not a guarantee that services will be offered to you.

      By clicking the Submit Request button below, you are providing consent for UnitingSA to record and store the personal information provided in this referral, along with any other documentation that you have provided, in our secure information systems.
      Consent
      Donate

      Nobody can do everything but everyone can do something.

      UnitingSA relies on the generosity of donors to help deliver innovative programs and support for people in need across metropolitan and regional South Australia.

      People Supported

      12,537

      “I would still be on the streets if it wasn’t for the support of UnitingSA. It means the world to me to have a house for my whole family and to be able to tuck my children in at night.”

      William,
      Received support from UnitingSA Homelessness Services

      UnitingSA was established in 1919 and provides housing, aged care and community services to support people across regional and metropolitan South Australia. More than 1000 employees and volunteers deliver high quality services to more than 12,000 people from diverse backgrounds to realise UnitingSA's vision of a compassionate, respectful and just community in which all people participate and flourish.

      UnitingSA acknowledges the traditional owners of country throughout South Australia, their spiritual heritage, living culture and our walk together towards reconciliation.

      UnitingSA is committed to safe and inclusive work places, policies and services for LGBTIQ+ communities and their families.


        Aboriginal Flag design by Harold Thomas   Torres Strait Islander Flag design by the late Bernard Namok   Progress Pride Flag design by Daniel Quasar

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      Contact

      unitingsa@unitingsa.com.au

      (08) 8440 2200

      Location

      70 Dale Street
      Port Adelaide, SA 5015

      Postal Address

      P.O. Box 3032
      Port Adelaide, SA 5015

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      Emergency Assistance Suburbs

      UnitingSA is only able to provide material assistance (food and/or clothing vouchers etc.) to individuals and families residing in the Western suburbs of Adelaide.

      Suburbs in our current service area are listed below.

      Suburb
      Postcode
      Alberton
      5014
      Albert Park
      5014
      Birkenhead
      5015
      Cheltenham
      5014
      Ethelton
      5015
      Exeter
      5015
      Findon
      5023
      Fulham
      5024
      Fulham Gardens
      5024
      Gillman
      5013
      Glanville
      5015
      Grange
      5022
      Hendon
      5014
      Henley Beach
      5022
      Henley Beach South
      5022
      Kidman Park
      5025
      Largs Bay
      5018
      Largs North
      5016
      New Port Quays
      5015
      North Haven
      5017
      Osborne
      5017
      Ottoway
      5013
      Pennington
      5013
      Peterhead
      5016
      Port Adelaide
      5015
      Queenstown
      5015
      Rosewater
      5013
      Royal Park
      5014
      Seaton
      5023
      Semaphore
      5019
      Semaphore Park
      5019
      St Clair
      5011
      Taperoo
      5017
      Tennyson
      5022
      West Lakes
      5021
      West Lakes Shore
      5020
      Wingfield
      5013
      Woodville
      5011
      Woodville West
      5011
      West Beach
      5024

      NDIS referral form

      Request for services

      Client Advisory Workshop

      Registration Form

      Quality Care Advisory Committee

      Nomination Form

      A gift for the 40%

      Items must be new, unopened and in their original packaging.

      • Toiletries packs
      • SunSmart items – bucket hats, UV protection sunglasses
      • Flameless decorative candles
      • Aftershave
      • Perfume
      • Light up magnifying mirror
      • Aroma diffuser sticks
      • Perfumed wardrobe or draw liners
      • Bluetooth Waterproof Speaker
      • Clock Radio AM/FM – with larger time, date and some include weather display too
      • Retro flip clock
      • Projector style night lights for children but also work well as a present for aged care residents
      • Low vision keyboard
      • Long handled or extendable shoe horn
      • Warm flat slippers
      • Mirror and comb
      • Mirror and old style bristle brush
      • Non slip style socks
      • Cotton cardigan, navy, forest green, grey, black
      • Cotton, wool or viscose vest or sleeveless jumper – available from Kmart, Suzanne Grae, Best Less, Harris Scarfe, Big W, Target
      • Cotton jumper, soft pastels or patterned
      • Soft occasional cushion or a throw blanket
      • Small canvas art or decorative items

      Items of Greatest Need

      Items must be new, unopened and in their original packaging.

      • Sets of sheets, single, double or queen – double is most popular
      • Twin pack of pillows
      • Quilts, doonas or blankets
      • Bath towel and face washer
      • Sleeping bags
      • Swags
      • Travel size toiletries packs for adults and children
      • Personal hygiene items
      • Nappies from newborn to toddler
      • Wipes safe for children

      Toys & Gifts

      Items must be new, unopened and in their original packaging.

      Toys & gifts for children 0-10 years of age

      • Baby bath soap/toys
      • Soccer balls, basketballs, footballs
      • Lego or Duplo sets
      • Play-Doh single pots and sets
      • FurReal Pets
      • Frozen characters, colouring books and activities
      • Character bike helmets
      • Scooter, trike or bicycle
      • Disney character or similar dolls
      • Matchbox or Hot Wheels toys
      • Books/novels
      • Wooden puzzles – toddlers
      • Dinosaur model kits
      • Bug catchers
      • Board games like wooden Chess & Draughts, Jenga, Guess Who, Connect 4, tabletop Air Hockey, Scrabble – all ages
      • Disney/Harry Potter puzzles
      • Soft play mats for babies
      • Alphabet soft mats for toddlers
      • Summer/Christmas PJs
      • SunSmart items – bucket hats, UV protection sunglasses, UV-resistant swimsuits/rashies/Sun shades
      • Beach gear including towels

      Tweens & Youth 10-18 years of age

      • Travel size toiletries packs
      • Dreamcatchers
      • Flip flops/thongs/slides
      • Flameless decorative candles
      • Aftershave
      • Perfume
      • Make-up packs
      • A5 journals with a pen
      • Mindfulness-style colouring books that include set of pens
      • Books/novels/non-fiction/photography/mindfulness
      • Puzzles or board games
      • Lipstick/lip gloss and small mirror
      • Boxed chocolates & lollies like Favourites, Party Mix, Snakes
      • Summer/Christmas PJs
      • Bluetooth waterproof speaker
      • SunSmart items – bucket hats, UV protection sunglasses, UV-resistant swimsuits/rashies
      • Beach gear including towels and bathers/boardies/thongs
      • Bikes
      • Helmets
      • Basic unlocked mobile phones or phone credit
      • Gift cards – Kmart, JB-HIFI, BIG W, Platypus Shoes, Skechers, General Pants, Cotton On $15, $25, $50, $75 or $100

      Individual adults, parents & guardians

      • Travel size toiletries packs for adults and children
      • SunSmart items – bucket hats, UV protection sunglasses,
      • UV-resistant swimsuits/rashies/boardies
      • Mirror and comb or brush
      • Flameless decorative candles
      • Aftershave
      • Perfume
      • Boxed chocolates & lollies
      • Lipstick/lip gloss and small mirror
      • Puzzles or Bboard games
      • Books/novels/non-fiction/photography/mindfulness
      • Mindfulness-style colouring books that include set of pens
      • A5 journals with a pen
      • Make-up packs
      • Summer/Christmas PJs
      • Track pants size S, M, L
      • Zip up hoodies size S, M, L
      • Men’s short sleeve shirt size S, M , L – can be a polo style with a collar and a pocket
      • Ladies shirts size S, M, L – can be festive colours, floral cotton or viscose short sleeve shirt
      • Flat slippers, slides or thongs
      • Bluetooth waterproof speaker
      • Clock radio AM/FM
      • Basic unlocked mobile phones or phone credit

      Festive Food Items

      Items must be unopened and within their best-before or use-by date.
      Items most needed:

      • Christmas bon-bons
      • Christmas serviettes
      • Packs of bottled water (600ml)
      • Fruit juice boxes for children (250ml)
      • Shortbread (200g packets)
      • Small Christmas puddings (microwavable)
      • Christmas fruit mince pies
      • Cadbury Sharepack Marshmallow Santa
      • Cadbury Sharepack Magical Elves
      • Smyths Christmas Lollies Mixture
      • Roses or Favourites boxed chocolates
      • Cadbury Dream White Christmas Family Block
      • UHT custard (1 litre)
      • UHT milk (1 litre)
      • UHT whipping cream
      • UHT small flavoured milks
      • Cranberry jelly/sauce
      • Self-saucing puddings (microwaveable)
      • Picnic size salt and pepper
      • Squeezy mayonnaise
      • Tomato sauce

      Non-perishables

      Items must be unopened and within their best-before or use-by date.
      Items most needed:

      • Packs of bottled water (600ml)
      • Cup a Soup
      • Cup-a-Noodles
      • Ready-made pasta sauces in jars
      • Dry pasta; spaghetti, macaroni, penne are most popular
      • Dry rice noodles
      • UHT milk 1 litre, full cream, low fat, skim and lactose free
      • UHT milk alternatives: oat, almond, soy
      • UHT small flavoured milks
      • Spreads: vegemite, peanut butter, jam, honey
      • Breakfast cereals
      • Tea bags, instant coffee & herbal tea bags
      • Nesquik, Milo or hot chocolate mix
      • Muesli bars
      • Mixed nuts and trail mixes
      • Mixed dried fruit
      • Canned tuna, salmon, chicken or turkey
      • Canned soups
      • Canned baked beans & spaghetti
      • Canned vegetables: green beans, carrots, corn, peas, potatoes, mushrooms
      • Canned fruit: peaches, pears, fruit salad
      • Heinz Big & Chunky meals in a can range
      • Tom Piper Braised Steak & Onion in a can
      • Fray Bentos Steak & Gravy or Steak & Kidney pie in a can range
      • Shelf-stable meals (food that can be stored at room temperature, vacuum sealed)

      Everyday Essentials

      New, unused items most needed:

      • Travel size toiletries packs for adults and children
      • Personal hygiene items
      • Nappies from newborn to toddler
      • Wipes safe for children
      • Packs of bottled water (600ml)

      Winter Essentials

      New, unused items most needed:

      • Tents and tarps
      • Swags for two
      • Sleeping bags
      • Beanies, jumpers, socks, jackets, fleecy hoodies and track pants for all ages
      • Sets of flannelette or plain sheets, single, double or queen – double is most popular
      • Sleeping pillows
      • Quilts, doonas or blankets
      • Bath towels and face washers
      Call Now!