* Referral Form

  • Affinity Health Solutions Referral Submission

    Please make a selection below to begin the process

  • Please note: Our current wait time for new referrals is 4 - 6 weeks.

    If you would like suggestions on recommended alternate community nursing providers, please email manager@affinityhealthsolutions.com.au

     

    A New, Focused Approach to NDIS Nursing Services

    At Affinity Health Solutions, we are evolving our NDIS nursing services to deepen our impact. We have transitioned to a dedicated, capacity-limited program to ensure optimal resource allocation and strengthen client outcomes, prioritising participants who we are able to provide the most significant clinical impact.

    While this means we can only accept a select number of new referrals, we warmly invite you to submit an enquiry for our consideration. We will continue to assess each referral individually and we welcome the opportunity to discuss how our specialised practice could align with your participants' needs.

  • NDIS Participant Referral Form

    Please note that Affinity Health Solutions is not a crisis clinical service. In an emergency, please ensure the participant presents to the Emergency Department. Please note: Affinity Health Solutions is NOT registered for paediatrics.

  • 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

     

  • Your Details

  • Participant / Client Details

  • Gender*
  • Date of birth*
     / /
  • What is the best way to contact the participant or guardian?*
  • Who are we contacting to make an initial appointment with the participant?*
  • Is this participant requiring telehealth services due to location?
  • Clinical service level*
  • 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.*
  • Do any of the following apply to the participant? (select all that apply)
  • How does the participant communicate?*
  • Does the participant require any of the following to assist with communication?
  • Do they have any cultural or religious requirements that we need to be aware of?
  • Does the participant have a preference between male or female nurses?
  • Is the participant currently engaged with any of the following services? (select all that apply)*

  • NDIS Details

    If the person is funded through a different insurance company or is privately managed, please proceed to the next section. Type N/A and make any selection where field selection is required.
  • What is the funding type?*
  • Where is the funding being taken from?*
  • Is the funding managed in quarterly installments?*
  • Who is the Service Agreement being sent to for signing?*
  • Please indicate what format the Service Agreement should be in:

  • Reports - End of Plan, S100 & Other

  • 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*

  • Risk Management

  • Does the participant have a Positive Behaviour Support Plan? If yes, please upload the document below.
  • Is there a history of substance abuse involving the participant or others in the household?*
  • Is there a history of aggression and/or violence of therapeutic supports involving the client or others in the household?*
  • Is there a history of non-compliance of therapeutic supports involving the client or others in the household?*
  • If there are pets, can they be put away while we attend?*
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  • 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.

  • Private / Other funded clients

    Please note that Affinity Health Solutions is not a crisis clinical service. In an emergency, please ensure the client presents to the Emergency Department. Please note: Affinity Health Solutions is NOT registered for paediatrics.

  • Your details

  • Client details

  • Date of Birth*
     - -
  • Gender*
  • Is the client requiring telehealth services due to location?
  • What is the best way to contact the client?*
  • Who are we contacting to make an initial appointment with the client?*
  • Is there a set dollar amount for services or do you require a quote?*
  • Reason/s for referral; you may select more than one (Please note that all services require an assessment of the client).*
  • How does the client communicate?*
  • Do any of the following apply?
  • Do they have a preference between male or female nurses?
  • Are they currently engaged with any of the following services? You may select more than one.

  • Risk Management

  • Does the client have a Positive Behaviour Support Plan? If yes, please upload the document below.*
  • Is there a history of substance abuse involving the client or others in the household?*
  • Is there a history of aggression and/or violence of therapeutic supports involving the client or others in the household?*
  • Is there a history of non-compliance of therapeutic supports involving the client or others in the household?*
  • If there are pets, can they be put away while we attend?
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  • 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.

  • Specialist Referrals

    Please note: Affinity Health Solutions is not apart of Medicare or other financial benefit schemes

  • Client details

  • Date of Birth
     - -
  • Gender
  • What is the best way to contact the client?*
  • How does the client communicate?*
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