* Referral Form

Affinity Health Solutions utilises a minimum of 10 hours of funding. We are able to claim from Core if there is not enough funding in CB IDL budget.

Please note: There is currently a 4 - 6 week wait time for services. If your referral is urgent or you have questions, please send your enquiry to the email address below and we may be able to make alternate nursing provider recommendations.

If the participant's plan has less than 10 hours of funding available or you have questions regarding funding, please contact the business manager to discuss on
0468 908 100 or email manager@affinityhealthsolutions.com.au

Name of referrer and organisation*

Contact number of referrer*

Email address of referrer*

Relationship to participant*

Full name of participant*

Gender*

FemaleMaleNon-binary/otherUnsure

Date of birth*

Date

Living arrangement e.g. alone, family/partner, supported accommodation, other*

Address of residence (please include full address)*

Contact phone number and/or email address for client, if applicable

What is the best way to contact the participant or guardian?*

Next of kin/guardian details (Please include their relationship to the participant, full name and contact details e.g. phone number and email address)*

Secondary emergency contact

Who are we contacting to make an initial appointment with the participant?*

* Please provide name and contact details if not elsewhere on this referral.

Is this participant requiring telehealth services due to location?

YesNo

Clinical service level*

High - complex e.g. vent/trachy, acute health deterioration, multiple complex diagnosesMedium - e.g. catheter and bowel management, wound management.Low - e.g. continence assessments and reports, health checks, telehealth appointments

Reason/s for referral (You may select more than one). All services listed require an assessment of the client. If you require a report, please see report section below.*

What is the registered NDIS primary diagnosis?*

Other diagnoses, current medical concerns or issues: *

If the client has a wound/s, please specify where.

Do any of the following apply to the participant? (select all that apply)

Alcohol abuseDrug abuseSmoker

How does the participant communicate?*

VerbalNon-verbalOther

Does the participant require any of the following to assist with communication?

TranslatorAdvocateFamily member/friend

Do they have any cultural or religious requirements that we need to be aware of?

YesNoUnsure

Does the participant have a preference between male or female nurses?

FemaleMaleNo preference

Is the participant currently engaged with any of the following services? (select all that apply)*

NDIS number*

Plan start and finish dates*

What is the funding type?*

Self-managedPlan-managedNDIA managedNDIA managed (PACE)

Where is the funding being taken from?*

CoreCB

What dollar amount of funding are you allocating to nursing services?*

Please list dollar amounts or hour units

Is the funding managed in quarterly installments?*

YesNoUnsure

Who is the Service Agreement being sent to for signing?*

Please indicate what format the Service Agreement should be in:

eDocumentPDFPaper copy

If plan-managed, please enter information below (name, contact phone number and email etc)*

Please note there may be up to a four to six (4-6) week wait time for NDIA required reports and other reports.

If you require a report completed urgently please contact Sian, Business Manager, on 0468 908 100 or manager@affinityhealthsolutions.com.au for current wait times.

If the report is for an S100 submission, please indicate in the 'Other' section, the date you are intending to submit the S100.

Please note that all reports include a comprehensive consumables costing quote.

Please indicate what type of report you require*

Other or N/AFull comprehensive nursing reportContinence reportClinical summary

For 'other' and/or providing further details, please write your answer here.

Does the participant have a Positive Behaviour Support Plan? If yes, please upload the document below.

YesNoUnsure

Is there a history of substance abuse involving the participant or others in the household?*

YesNoUnsure

Is there a history of aggression and/or violence of therapeutic supports involving the client or others in the household?*

YesNoUnsure

Is there a history of non-compliance of therapeutic supports involving the client or others in the household?*

YesNoMaybe

If there are pets, can they be put away while we attend?*

YesNoUnsure

Is there any difficulties accessing the property? (e.g. gated community, address does not display correctly on navigational maps, coded access etc)

Please upload the clients NDIS plan and any other relevant documents such as recent other therapy reports, BSP's, other nursing reports, hospital discharge letters etc.*

Is there any other relevant information we need to know?

How did you hear about us?

By submitting this form you acknowledge that you have spoken with the client/their guardian regarding engaging our services, and they are aware that you are submitting this referral on their behalf.

Affinity Health Solutions Referral Submission

NDIS Participant Referral Form

Your Details

Participant / Client Details

NDIS Details

Reports - End of Plan, S100 & Other

Risk Management

Private / Other funded clients

Your details

Client details

Risk Management

Specialist Referrals

Client details