Referral Form (Lifeheart)

Participant Intake Form
Lifeheart specialises in Home & Living supports (SIL & ILO), including transition support for participants working toward this outcome.

Drop-in support & Respite is available by review only — please discuss with us first on josh@lifeheart.com.au.

Please allow 15 minutes to complete this form and have any relevant reports and assessments ready to upload. You may save this form at any time by clicking 'save' at the bottom.
1. Referrer Details
Referrer Name:*

First NameLast Name
Mobile number*
Relationship to Participant:*
Email contact: *
Will you be the primary contact person for the participant?*

YesNo
Primary Contact Name (if different)
Primary Contact Person Details
How is the participant's funding managed?*

Self-ManagedPlan-ManagedNDIA Managed
Plan Manager Details
2. Participant Details:

Please enter as much information as possible
Participant Full Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Gender:
Home Address:*
Primary Disability / Diagnosis*
eg. Autism, Intellectual Disability or Other
Secondary Disability / Diagnosis
What is the Participants living situation?

Parents or FamilyNominated CarerLiving independently / RentalSupported Independent LivingIndependent Living Option
Preferred Worker Gender (if any)
Preferred Worker Language / Cultural Background
3. Risk & Safety

Please complete this section carefully. It helps us determine whether we can safely support this participant and how to prepare our team.
Are there any restrictive practices currently in place or previously authorised?

YesNo
If yes, please provide details of the Behaviour Support Practitioner:
Does the participant have a Behaviour Support Plan (BSP)?*

YesNo
If yes, please upload the BSP below:

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Does the participant have a history of behaviours of concern (e.g aggression, property damage, absconding)*

YesNo
If yes, please describe:
Does the participant have a history of self-harming behaviour?*

YesNo
If yes, please describe:
Does the participant have a history of risk-taking behaviour*

YesNo
If yes, please describe:
Does the participant have a history of substance misuse?*

YesNo
If yes, please describe:
Please describe any other challenges, triggers or environmental factors we should be aware of:
4. Functional Needs
Primary communication method*

VerbalAAC DevicePECSAuslan / SignWrittenOther
If other communication method, please describe:

Level of support needed for daily activities (1 = Independent, 2 = Prompting only, 3 = Partial assist, 4 = Full assist)*

Rows	Level (1-4)	Notes
Personal Care / Hygiene
Meal preparation
Medication management
Mobility / transfers
Continence / toileting

Does the Participant have sensory sensitivities we should know about?*

YesNo
If yes, please describe (e.g noise, texture, light):
Does the Participant require manual handling (e.g hoist, slide sheet)*

YesNo
Equipment / technique details:
Does the Participant require a Mealtime Management Plan?*

YesNo
If yes, texture, supervision level, or referral to plan:
If yes, please upload the Mealtime Management Plan below:

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Does the Participant require an Interpreter?

YesNo
Language / communication support needed:
5. NDIS Information
Does the Participant have an active plan?*

YesNo
NDIS Participant Number:*
Plan Start Date:
Plan Review / Renewal Date:
Support Coordinator / LAC Name & Contact
NDIS Goals you would like us to work towards:*
List up to 5 goals. These will guide our support planning.
Which Support Purposes would you like us to utilize:*

Core SupportsCapacity Building
Which Support Category would you like us to utilize:*

01 Assistance with Daily Life02 Transport04 Assistance with Social, Economic and Community Participation08 Improved Living Arrangements09 Increased Social and Community Participation11 Improved Relationships15 Improved Daily Living SkillsOther
Is the support category required for the participant listed as High Intensity?

YesNo
Is the referral related to the following supports: *

Supported Independent Living (SIL)Independent Living Options (ILO)NoI need help exploring this
Please list the intended funding amounts you would like us to utilize:
e.g Assistance with Supported Accommodation - $XX XXX
If you would prefer, please upload the current NDIS Plan:

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6. Requested Support Schedule

Please enter the requested support schedule (we will try our best to accomodate):

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Night

Preferred frequency / additional schedule notes*
7. Medical Information
Medical conditions we need to be aware of:*
eg. epilepsy, diabetes, immune concerns, cardiac conditions
Does the participant have any allergies?*

YesNo
Please list:
Does the participant take any medications?*

YesNo
List medication, dose, and frequency:
Does the participant require medication management from us?*

YesNo
Does the participant have any swallowing concerns or Dysphagia?*

YesNo
Is there a formal Mealtime Management Plan?
Are there any first aid requirements we should prepare for (e.g seizure protocol?)*

YesNo
If yes, please describe:
8. Allied Health & Formal Support Network

This helps us build a comprehensive support plan and draw on exisiting knowledge.
Please list allied health providers:*
Eg. Occupational Therapist: Andrew Brown - Sunshine Therapies - Email Address - Phone Number
Do you consent for Lifeheart to contact allied health providers?

YesNo
Please upload any other reports or specialist assessments:

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9. Participant Interests & Goals
Existing hobbies, activities or interests:*
This helps us match the right worker and plan meaningful activities
What does a good day look like for this participant?
Consent and Declaration
By completing this referral, you confirm that: (1) you have authority to act on the participant's behalf as their representative under the Privacy Act 1988; (2) all information submitted is accurate and complete to the best of your knowledge; (3) you consent to Lifeheart keeping a record of this referral and using the information to develop a support plan and service agreement; (4) you agree for Lifeheart to contact you or the participant's guardian for follow-up communication regarding their care.

Website: www.lifeheart.com.au

Phone: 0405061741

Contact: josh@lifeheart.com.au
Participant Representative:
Participant Signature (if required)
Do you consent for Lifeheart to create a support plan using the provided information:*

YesNo
Should be Empty:

Participant Intake Form

1. Referrer Details

2. Participant Details:

3. Risk & Safety

4. Functional Needs

5. NDIS Information

6. Requested Support Schedule

7. Medical Information

8. Allied Health & Formal Support Network

9. Participant Interests & Goals

Consent and Declaration