Client Intake Referral Form
Participants Details
Participants Full Name
*
First Name
Last Name
Participants Date of Birth
Please select a month
January
February
March
April
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December
Month
Please select a day
1
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Day
Please select a year
2025
2024
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1922
1921
1920
Year
Participants NDIS Number
*
Participants Email Address
*
example@example.com
Participant Phone Number
*
Please enter a valid phone number.
Participants Gender
Female
Male
Non Binary
Prefer not to say
Participants Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participants Funding Information
Participants NDIS Plan Start Date
*
-
Month
-
Day
Year
Date
Participants NDIS Plan End Date
*
-
Month
-
Day
Year
Date
Participants Funding Type
*
Plan Managed
NDIA Managed (Agency)
Self Managed
If Plan Managed or Self Managed, Please Write Down Their Email. If Not, Please Write NA
*
Which line item will the funds be coming from?
*
Assistance With Self-Care Activities - Standard
House Cleaning And Other Household Activities
Access Community Social and Rec Activ - Standard
Access Community Social and Rec Activ - High Intensity
Activity Based Transport
Assistance in Supported Independent Living - Standard
Assistance in Supported Independent Living - High Intensity
Group Activities - High Intensity
Group Activities - Standard
Other
If other, please write it down.
Participants Diagnosis
Participants Medical Diagnoses / Medical History
*
Reason For Referral?
*
Any Behavioural Risks Associated with the Participant?
*
Kindly attach any Risk Assessment or Behavioural Support Plans. If unable to upload, kindly email to: Info@lhdisabilityservices.com.au
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Does the participant use any mediciations or drugs?
Yes
No
Not applicable
If yes to using medications or drugs, kindly name them in the box below
Service Information
Requested Services
*
Personal Care
Community and Social Access
Assistance with Daily Life
Supported Independent Living
Centre & Community Based Program
Support Coordination
Assistance with NDIS Application
Travel & Transportation
Respite
Household Cleaning
ILO Accomodation
Requested Service Dates. Place in '' if if is the same hours and time
*
Hours of Service
Description of Support
Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Referrer Details
Referrer Name
*
First Name
Last Name
Referrer Email Address
*
example@example.com
Referrer Phone Number
*
Please enter a valid phone number.
Referrer Organisation (if not related to participant)
*
When Do You Want Services to Commence?
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Facebook
Website
Word of mouth
Instagram
Email
Other
Participants Emergency Contact Full Name
First Name
Last Name
Participants Emergency Contact Phone Number
Please enter a valid phone number.
Participants Emergency Contact Email Address
example@example.com
Emergency Contact Relationship to the Participant
Kindly attach NDIS Plan. If you are unble to upload them, kindly email is to: Info@lhdisabilityservices.com.au
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Referer Signature
*
Should be Empty: