NDIS Services Referral Form We provide services for people with disability in our onsite rehab gym or at home. NDIS Referral Form Participant Details * First Name Last Name Date of Birth * MM DD YYYY Gender * Female Male Non-binary Other Email * Phone * (###) ### #### REFERRAL DETAILS Has the participant been notified that a referral has been made? Yes No What services are the participant interested in? Physiotherapy Exercise Physiology Group class Hydrotherapy Where would the services be accessed? Clinic / Rehab Gym Home FUNDING DETAILS NDIS Number * Plan end date * MM DD YYYY Fund Management * Plan Self Plan Manager Details MEDICAL HISTORY Disability / Diagnosis Other Medical History / Allergies BEHAVIOURAL CONSIDERATIONS Any challenging behaviours: Any sensitivities / triggers? e.g. loud noise, number of people etc. COMMUNICATION Does the participant speak English as their first language? Yes No. If so, what is their first language? Details Does the participant require an interpreter? Yes No Does the participant require support with communication? Yes No Details MOBILITY & TRANSFERS What level of physical assistance do you require with your mobility & transfers. * Independent Supervision Physical Assist x1 Physical Assist x2 Other Details Do you use any assistive technology to assist with your mobility or transfers. Walking aid Self propelled wheelchair Electric wheelchair Stand lifter Sling hoist Other HOME VISIT DETAILS Only fill out if relevant to the participant Are any of the following risks present in the home: Are there any aggressive or disruptive pets in the house? Does anyone smoke inside the house? Is there presence of violence or aggression from anyone in the residence? Are there known illicit substances in the home? Are there known weapons or firearms in the house that might be dangerous? If yes, provide a comment or possible resolution: SUPPORT COORDINATOR DETAILS Name First Name Last Name Email Phone (###) ### #### Text Organisation APPOINTMENTS Who should we communicate with regarding appointments? Participant Support Coordinator Family Member Nominated Person Other Name If applicable First Name Last Name Phone (###) ### #### Email Thank you!
