Service Referral & Support Plan Form

Participant NDIS Number *

Participant Name *

Gender

Phone *

Date of Birth *

Address *

Email *

Participant's Guardian Name

Relationship with Participant

Guardian Email

Guardian Phone

Support Coordinator

Organisation

Support Coordinator's Email

Support Coordinator Phone

Emergency Contact

Relationship with Participant (2)

Emergency Contact Email

Emergency Contact Phone

Language Spoken *

English Others

Interpreter Required *

Yes No

Does the Participant live alone? *

Yes No

Is the participant supported by only one support worker? *

Yes No

NDIS Plan Manager *

NDIA Managed Plan Managed Self Managed

Managed by

Accounts Email

What Support Services are you looking for? (Select all applicable). *

Disability Support Worker Supported Independent Living Assistance with Domestic Household Tasks (Cleaning / Gardening etc). Support Coordination Assistance with Community participation

Service Start Date *

Service End Date *

Service Provider *

Primary Disability *

Secondary Health/Medical Conditions

Allergies/Alerts

Support services Start Date

Describe the support needs required: *

Is the participant at risk of choking, seizures or anaphylaxis? *

Yes No

Is assist with medication administration required? *

Yes No

Does participant suffer from irritants, phobias or any other specific condition? *

Yes No

Is participant home easy to locate? *

Yes No

Any pets or animals at home? *

Yes No

Is the home wheelchair accessible? *

Yes No

Are any gates or doorways difficult to use or access? *

Yes No

Is onsite/street parking available for support worker’s car? *

Yes No

Are there any slip, trip or falling hazards outside or inside the home? *

Yes No

At night, is the house entrance hard to find? *

Yes No

Is there a risk that participant may abscond? *

Yes No

Will the support worker be required to use any electric appliances? *

Yes No

Do you give consent for the support worker to proactively support you in attending medical, and allied health services? *

Yes No

Do you give consent to share this form with your support network, other providers, and relevant government agencies? *

Yes No

In case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting points?

Are there any specific risks associated with transport?

Are there any places, situations or specific irritants that should be avoided?

Is there anything else you would like to share about the participant or home?

NDIS Document / Current Plan

Drag & Drop Files, Choose File to Upload

Participant / representative Signature *

Sign above using mouse or finger

How did you hear about Us? (Select all applicable). *

Facebook Google advert Referred LAC / SC Other NDIS Website

Date *