AmeCare - Referral Form [easy-read]

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Referral Form
Who is this referral for?

Other
What service are you looking for?

Other
ABOUT YOU
Your name:

First NameLast Name
Your Date of Birth (DOB)

DayMonthYear
Date
Do you have another name, or a nickname?
Your pronouns:
e.g., they/them/theirs, she/her/hers, he/him/his, etc
Relationship Status

Other
Your Gender:

Other
Do you need an Interpreter?
If Yes, please provide additional information:
Your Religion/ Spirituality (optional)
What country were you born in?
What language/s do you speak?
ATSI?
What have you been diagnosed with? Do you have any medical alerts?
CONTACT DETAILS
Mobile:
Format: 0000 000 000.
Landline:
Format: (00) 0000 0000.
E-mail:
example@example.com
How would you like us to contact you? (You can tick more than one)

Other
Your current or last postal address
Where are you currently living?

Other
EMERGENCY CONTACT / NEXT OF KIN / LEGAL GUARDIAN
(the best person to contact in an emergency)
Name
Relationship to you
Contact Number
Email
Are there other people or organisations involved in supporting you?
SUPPORT NETWORK

(informal/formal connections e.g., financial administrator, current NDIS supports, plan nominee, family members, etc)
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
Name
Relationship to you
Contact Number
Email
A bit more about you...
Your Goals - what do you want us to help you with?
These can be your NDIS goals and/or your own personal goals
Funding Source

Other
Pension Reference #
Expiry (MM/YYYY)
Medicare Reference #
Expiry (MM/YYYY)
NDIS Reference #
Do you have any documents (like support plans or therapist reports) that can help us understand your needs?

Yes:
If Yes, please attach them below:

Cancelof
Support Requirements

How often would you like support?

Rows	Every day	A few days a week	Once a week	Only when I ask for it
At home support
Community Access

Do you need help with medication?
If Yes, please provide any additional/relevant details:
E.g., what type of medication? what type of support?
Do you use any mobility aids or sensory equipment? (e.g., wheelchair, walking frame, hearing aids, etc)
If Yes, please provide any additional/relevant details:
E.g., what type of aids or equipment do you use?
Please include any additional details about the information collected...
Prompts: Did you answer "other" to any questions? Tell us a few things that are important to you (e.g., location, accessibility). What things help you feel comfortable, or make you feel uncomfortable? Or, any other details that can help us understand and support you to the best of our ability!

Nearly done!
Name of person submitting this form
If you are submitting this form on behalf of someone else, please also include your relationship to the person being referred.
Signature of person submitting this form
Please verify that you are human
Should be Empty:

Rows	No help	Some help	A lot of help	Not sure, or not relevant
Personal Care
Choking or swallowing
Using electronics
Hurting myself or purpose
Falling
Socialising with other people
Getting around new or unfamiliar areas
Catching public transport
Safety around fires
Speaking up for myself
Handling money
Cooking and preparing meals
Grocery shopping
Doing my laundry
Using taxis or travelling in a car
General house cleaning like vacuuming and dusting
Washing dishes
Being impulsive
Remembering things
Having a routine or planning ahead
Dealing with unexpected changes
Communicating when I need support
Keeping on top of my health and wellbeing
Help going up or down stairs
Using emergency services
Knowing when I feel unwell
Substance use - drug
Substance use - alcohol
Smoking - tobacco
Trying not to be evicted from home

Rows	Yes	No
AGGRESSION or VIOLENCE?
STALKING?
SEX OFFENCES?
DOMESTIC VIOLENCE?
PROPERTY DAMAGE?
STEALING or THEFT?

Referral Form

ABOUT YOU

CONTACT DETAILS

SUPPORT NETWORK

A bit more about you...

Support Requirements

Safety Assessment

Nearly done!