Amazing Grace Intake / Referral Form

Participant Referral Form

Please complete the information relevant to the service you are requesting.
Participant Name*

PrefixFirst NameMiddle NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Participant NDIS Number*
Plan Dates (start and finish dates):*
Is the Participant:*

AboriginalTorres Strait IslanderBoth Aboriginal & Torres Strait IslanderNeitherCulturally & Linguistically Diverse (please state)
Guardian / Nominee Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
NDIS Support Coordinator or Specialist Support Coordinator
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Plan Management*
Select all that apply where there is a combination of management types.
If Plan Managed, please provide details.

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Service Request Details

Please complete this section to the best of your knowledge.
What service/s are you requesting?*

Supported Independent LivingMedium Term AccommodationShort Term Accommodation / RespiteIndividual Living OptionsDrop-In SupportsCommunity AccessOther
What support ratio is the participant requiring?*

1:11:22:1Other
Please list the participant's diagnosis, along with any health conditions or mental health conditions.*
Please tick all that apply - the Participant has the involvement of:*

Forensic Mental Health TeamOccupational TherapistSpeech PathologistSpecialist Behaviour Support PractitionerComplex Behaviour UnitPublic TrusteePublic GuardianForensic Disability UnitPhysiotherapistProbation & Parole Office

Please indicate preferred days/times of supports:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Overnight

Support Type Item Number / Decription/s
Please list Price Guide item number/s
I would like the service to commence on:*

DayMonthYear
I would like the service to cease on:

DayMonthYear

Participant Mobility / Capacity*

	Always needs help or supervision	Sometimes needs help or supervision	Does not need help but uses aids or equipment	Does not need help and does not use aids or equipment
Walking
Eating
Showering
Personal care
Using the toilet
Dressing
Transport
Communication
Interpersonal Relationships
Community Participation

Does the participant have GP clearance to self-administer medications while accessing STA, MTA, SIL or Respite?*

YesNo
Please upload any relevant information such as medication information, NDIS plan goals, Allied Health and Clinical reports, etc.

Cancelof
Consent Form - Authority to Collect, Use and Disclose Client Information
Personal information collected by Amazing Grace is protected by the Privacy
Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act).

The primary purpose for collecting personal information from you is to:
- determine eligibility for services and/or waitlist management
- respond to your feedback or complaints, and
- answer your queries.
Amazing Grace will not disclose/use information about you for any secondary
purpose, Unless:
- You have consented to the use or disclosure; or
- The use or disclosure of the information is required or authorised by or
  under an Australian law or a court/tribunal order; or
- Amazing Grace reasonably believes the use or disclosure is necessary to
  lessen or prevent a serious threat to life, health, or safety of an individual or
  to public health and safety; or
- Amazing Grace has reason to suspect an individual may have done
  something unlawful or engaged in serious misconduct that relates to
  Amazing Grace functions or activities;
- Amazing Grace reasonably believes that the use or disclosure is reasonably
  necessary to assist another person to locate a person reported as missing.
I, Guardian / Nominee / Approved person to provide consent*give authority for Amazing Grace; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs in accordance with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a client of Amazing Grace. If my/our circumstances change I agree to notify Amazing Grace as soon as practicable.
Signature*

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Participant Referral Form

Guardian / Nominee Details

NDIS Support Coordinator or Specialist Support Coordinator

Service Request Details

Consent Form - Authority to Collect, Use and Disclose Client Information