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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*
    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
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    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.
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      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

      “We love Hawksbury Gardens so much, your staff have been so supportive and have made this process so wonderful, we can’t thank you enough!”

      Cassie,
      Family member, Residential Aged Care

      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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      Port Adelaide, SA 5015

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