Service Referral & Support Plan Form – Cosmos Divine Care

1800 953 997

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1800 953 997

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Participant NDIS Number *

Phone *

Email *

Participant Name *

Date of Birth *

Gender

Address *

Address Line 1

City

State / Province / Region

Country

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Participant's Guardian Name

Relationship with Participant

Guardian Email

Guardian Phone

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Support Coordinator

Organisation

Support Coordinator's Email

Support Coordinator Phone

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Emergency Contact

Relationship with Participant

Emergency Contact Email

Emergency Contact Phone

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Language Spoken *

English
Others

Does the Participant live alone? *

Yes
No

Interpreter Required *

Yes
No

Is the participant supported by only one support worker? *

Yes
No

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

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Service Start Date *

Service End Date *

Service Provider *

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Primary Disability *

Allergies/Alerts

Secondary Health/Medical Conditions

Support services Start Date

Describe the support needs required: *

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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

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Is participant home easy to locate? *

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

Any pets or animals at home? *

Yes
No

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

Yes
No

Is there a risk that participant may abscond? *

Yes
No

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

Yes
No

Is the home wheelchair accessible? *

Yes
No

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

Yes
No

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

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?

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NDIS Document / Current Plan

Click or drag a file to this area to upload.

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

Facebook
Google advert
Referred
LAC / SC
NDIS Website
Other

Participant / representative Signature *

Date *

Comment

About Us

As a Registered NDIS provider, Cosmos Divine Care provides services in a unique manner. Every participant receives a personalized approach and our services are tailored to meet the needs of each individual.

The Cosmos Divine Care team acknowledges the traditional owners and custodians of the country throughout Australia. We acknowledge their continuing connection to land, sea, and community. Respect is expressed to the people, the cultures, and the elders past, present, and emerging.

Contact Info

Office (by Appointments Only)

40 Le Page Run, South Morang, 3752 Victoria
1800 953 997
info@cosmosdivinecare.com.au

Further Information
What is NDIS?
Support Network - Ask Izzy
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