ETT Referral Form

Empowered Therapy and Training Nationwide Referrals

ABN: 55 637 079 620
This referral must be actioned:*

UrgentlyWithin the next 2 weeksWaitlistOther
Client Details
Are you a:*

Private ReferralNDIS Participant
If you were referred privately, you are encouraged to complete 10 sessions at a time. Do you agree?

YesNo
Client/Participant Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Current Client Diagnosis (ASD, OCD etc)*

Next of Kin - Contact #1*

Rows	Name	Phone Number	Email Address	Home Address	Relationship to Participant
Contact Details

Next of Kin - Contact #2*

Rows	Name	Phone Number	Email Address	Home Address	Relationship to Participant
Contact Details

Invoice to*

First NameLast Name
Invoicee's Organization Name*
Invoicee's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Invoicee's Email*
example@example.com
NDIS Participants Only
Participant Number*
Plan Type*

NDIS-managedPlan-managed (organisation-managed)Self-managedOther
Plan Start Date*

DayMonthYear
Date
Plan End Date*

DayMonthYear
Date

Please specify whether this is for Capacity Building, Core Supports or Daily Activities/ Other.*

Rows	$
Therapies
Plan Management
Support Coordination
Support Work
Transport
Equipment
Camp
Programs (see below)
Group-based activities
Other

Support Coordinator/Plan Manager

Rows	Name	Phone Number	Email Address	Organisation	Request
Details

What specific line item supports your/client's budget? (Example - 04_104_0125_6_1)
Short-term Goals*
Long-term Goals*
Therapeutic Supports

Art TherapyMusic/Movement TherapyPositive Behavioural SupportsCounsellingPsychologyOccupational Therapy (OT)Speech TherapyRecovery CoachDietitianDrama TherapyDrumming TherapyHypno-therapyLaughter TherapyPsychotherapySandplay TherapyTimeline TherapyNeurolinguistic Programming (NLP)Other
Other

Early Childhood SupportsCommunity/In-Home Support WorkersOther
Supports Required
Education

Life-skills learning program (adults and children)School of Life ProgramsAdult learning programsSchool-aged learning programsOther
If you would like to request supports for any education program, please fill out the following form after you have submitted the current referral form.

https://service.empoweredtherapyandtraining.com/school-of-life
Accommodation

Assistance with Accommodation and Tenancy ObligationsAssistance with Coordinating or Managing Life Stages, Transitions and SupportsAssistance with Daily Life Tasks in a Group or Shared Living Arrangement including Supported Independent Living (SIL) and/or RESPITEParticipation in Community, Social and Civic Activities (see activities below)Group and Centre Based Activities (see activities below)Other
If you would like to request supports for Home and Living, for example if you would like assistance to find accommodation (short or medium term), please fill out the following form after you have submitted the current referral form.

https://form.jotform.com/empoweredtherapy/request-for-home-and-living-support
Assessments

Behaviour Support (includes Positive Behaviour Support Plans)Mental, Social, Emotional, Behavioural, Cognitive AssessmentOther
If you would like to request supports for any formalised assessments , please fill out the following form:

https://form.jotform.com/empoweredtherapy/ett-formalised-assessments-registra
Group Activities

Day-Group Meet and Greets for school-leavers and Entertainment Days with activities like movies, bowling, animal feeding, horse riding, cooking, and art classes to help participants make new friends and socialise.Day-Group Educational Adventures provides enriching, hands-on learning experiences through activities like museum visits, science workshops, historical explorations, and nature discovery programs, fostering curiosity and knowledge in an engaging group setting.Day-Group Creative Hub offers fun after-school and weekend programs for school-aged children, focusing on artistic growth and self-expression through painting, drama, movement, and drumming circles and more – all designed to nurture creativity and social connections in an engaging environment.
Employment/Higher Education

Access and Maintain Employment or Higher EducationSpecialised Support EmploymentOther
Events (Face to Face or Online)
WEEKEND SELF-ESTEEM CAMPS (9 Week Programs)

QLD ASD (Autism) Relationship Building Self-Esteem Weekend Camps - 9 Week ProgramQLD Girl Pampering Self-Esteem Weekend Camps - 9 Week ProgramQLD Boys to Men Self-Esteem Weekend Camps - 9 Week Program
SCHOOL HOLIDAY SELF-ESTEEM CAMPS

SELF-ESTEEM SCHOOL HOLIDAYS 3-DAY CAMPS (Easter: April 16 - 18, 2025; Winter: July 9 - 11, 2025; Spring: October 1 - 3, 2025; Summer: January 14 - 16, 2026)RESILIENCE SCHOOL-AGED CAMPS (Gold Coast)
If you would like to enrol in any of our camps, please fill out the following form:

https://form.jotform.com/empoweredtherapy/kool-kids-camp-enrolment-form-filla
3-Day Events/Retreats

Parent and Child Connection Retreat 3-Day Getaway on a beautiful Sunshine Coast resort → June 7 - 9, 2025 // July 13 - 15, 2025 // December 13 - 15, 2025 // February 7 - 9 2026Who am I? (advanced level, 3 Day retreat) → June 3 - 6, 2025 // July 9 - 12, 2025 // December 9 - 12, 2025 // February 3 - 6, 2026
Train the Trainers (opportunity to become qualified facilitators and to gain potential employment)

Authentic Professional Speaker's Course (online and FTF) - learn to become a professional facilitator (2.5 day training)Laughter Facilitator (2 day course)Drumming Facilitator (2 day course)Domestic Violence Awareness Level 1 (2 day course)Domestic Violence Awareness Level 2 (2 day course)
Online Full-Day Workshops for All

Understanding the Children of Today (Full Day Workshop)Understanding and Living with Autism (Full Day Workshop)How NOT to Mess Your Child's Life - For Parents/Carers/Teachers etc. (Full Day Workshop)Mind-setting - if you change your thoughts, you change your life (Full Day Workshop)Find Out How Your Brain and Patterns of Behaviour Lie to You (Full Day Workshop)Managing Stress and Emotions for Teenagers (Full Day Workshop)
I want to know more about your events*

YesNo
Any further information you would like us to know:
Upload past assessments, reports and/or your NDIS plan here.

Cancelof
Files attached (see previous question and tick all that apply)

Past Assessment(s)Past Report(s)NDIS PlanOther
NDIS Support Categories and Support Item Numbers
Should be Empty:

Empowered Therapy and Training Nationwide Referrals

Client Details

NDIS Participants Only

Supports Required

Events (Face to Face or Online)