Finders Keepers WA Referral Form
NDIS Service Provider of Core and Capacity Building Supports
Participant Information
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State
Postcode
Gender
Please Select
Male
Female
Non-Binary
Trans Man
Trans Women
Agender
Gender Fluid
Intersex
Prefer not to answer
Other
Pronouns
Please Select
He/Him
She/Her
They/Them
ze/hir/hirs
Other
Prefer not to say
Date of Birth
*
-
Month
-
Day
Year
Date
NDIS Number
*
Plan Start Date
*
-
Month
-
Day
Year
Date
Plan End Date
*
-
Month
-
Day
Year
Date
Are there any Cultural or Language diversities?
Do you have any Allergies?
Do you have any Pets?
Condition or Diagnosis
Fund Management
*
Plan Managed
Self Managed
NDIA Managed
Plan or Self Managers Email if required
example@example.com
Next of Kin/ Guardian/ Alternative Contact
Relationship
Please Select
Parent
Spouse
Support Coordinator
Friend
Family
Partner
Sibling
Child
Type of Contact
Please Select
Next of Kin
Guardian
Parent of Child under 18
Alternative Contact
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Do you have a support coordinator or are you a support coordinator? Please provide details below
Other Contacts
Please provide other contact persons where applicable
GP Details
Dentist Details
Vaccination Details
Allied Health Details
Which of the following services will be needed for the Participant?
Multiple Selection is available
Social and Community Access
Accessing the Community
Transport
Assistance Attending Appointments
Community Engagement
Cultural Engagement
Other
Personal and Home Care
Medication Administering
Observation of Condition
Nutritional Support/ Feeding
Showering/Bathing
Manual Handling
Wound Care
Assistance with physical therapy
Hoist Transfer
Other
Capacity Building
Assistance With Accommodation And TenancyObligations
Skills Development and Training
Life Transition Planning Incl. Mentoring Peer Support And Individual Skill Development
Innovative Community Participation
Employment Support
Individual Social Skills Development
Transition through School and to Further Education
Assistance With Decision Making Daily Planningand Budgeting
Skill Development And Training including PublicTransport Training
Other
Service Goals
Additional Information (please tell us about yourself)
Preferences
Help us to make your service more specific for you
When would you like your service to start?
What would be your ideal days and times for service? Please include preferred shift times where possible.
What attributes would you like your support person to have? (please provide preferences such as age demographic, cultural backgrounds and gender)
Mental Health and Autism Participant Risk Assessment
Please use the following assessment for Autism or Mental Health Diagnosis
Does the participant display any of the following challenging behaviours?
Physical threats/actions
Verbal threats/actions
Absconding/Running away
Mouthing/Eating inedibles
Unwilling to follow instruction
Overtly loud or noisy
Impulsive/Agitated
Are there any plans in place to targeting the participants challenging behaviours? Is there a behaviour Support Plan in place?
Has the participant ever exercised force, towards any person including a caregiver that caused or could have caused injury?
Yes
No
Does the participant have a diagnosed mental illness (including paranoia)?
Yes
No
Is the participant currently taking any medication?
Yes
No
Does the participant smoke?
Yes
No
Does the participant have a history with substance abuse (illicit drugs/alcohol)?
Yes
No
Can the participant effectively communicate their wants and needs to others?
Yes
No
Does the participant currently engage in or have a history of self-injurious behaviours/self-harm?
Yes
No
Is the behaviour of the participant unpredictable?
Yes
No
Are there any triggers or sensory information we should be aware of?
Physical Disability Risk Assessment
Please use the following assessment for Physical or Neurological (inc autism) Diagnosis
Does the participant have swallowing difficulty or risks of choking?
Yes
No
Does the participant have a risk of falls?
Yes
No
Does the participant require assistance with communication or use a communication device?
Yes
No
Does the participant refuse to take medication?
Yes
No
Manual handling
Yes
No
Is there any of the below manual handling required?
vehicle access/ transfers
transfers
moving in bed
Other
Are there any accidental movements such as
startle reflex
grabbing, holding, leaning
sudden body movements
falling, tripping
Other
Submit
Should be Empty: