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.
Preferred method of contact
*
Please Select
Phone
Email
SMS
Are there any legal orders in place (Guardianship orders, public trustee, etc)
Address
*
Street Address
Street Address Line 2
City
State
Postcode
Gender
Please Select
Male
Female
Non-Binary
Transgender
Other
Prefer not to answer
Pronouns
Please Select
He/Him
She/Her
They/Them
Other
Prefer not to say
Date of Birth
*
-
Day
-
Month
Year
Date
NDIS Number
*
Plan Start Date
*
-
Day
-
Month
Year
Date
Plan End Date
*
-
Day
-
Month
Year
Date
Are there any Cultural or Language diversities?
Do you have any Allergies?
Do you have any Pets?
Primary Disability
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
Type of Contact
Next of Kin / Guardian / Alternative Contact
Full Name
First Name Surname
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
Name / Company / Contact Details
Other Health Contacts
Please provide other contact persons where applicable
GP Details
Dentist Details
Allied Health Details
Please list any other relevant Providers, Medical Professionals, Allied Health Professionals, NDIS Support Coordinators, NDIS Plan Management Agencies involved in the participants care. Please list below those that you allow us to contact, anyone else consent will be gained beforehand:
Which of the following services will be needed for the Participant?
Multiple Selection is available
Employment Supports
SLES
Finding and Keeping a Job
In Work Support
Microenterprise
Exploration
Pre-Employment Group Workshop
Voluntary Placement Support
Group Workshops
Other
Social and Community Access
Accessing the Community
Transport
Assistance Attending Appointments
Community Engagement
Employment Group Workshop
Other
Capacity Building
Assistance With Accommodation And Tenancy Obligations
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 Planning and Budgeting
Skill Development And Training including Public Transport Training
Employment Group Workshop
Other
Service Goals
NDIS Plan Funding Category
*
Core or Capacity?
Further Details, please include funding allocation for services:
*
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?
Does the participant have a history of aggression and violence towards others, including caregivers?
Yes
No
Does the participant have a diagnosed mental illness?
Yes
No
Is the participant currently taking any medication?
Yes
No
If you are taking regular medication, please list:
Does the participant smoke?
Yes
No
If you smoke, do you smoke inside the home?
Yes
No
Does the participant have a history of substance abuse (illicit drugs/alcohol)?
Yes
No
Does the participant current engage in 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? if so, please list deatils below in challenging behaviours
Yes
No
Are there any restrictive practices in effect? If so, please provide details
If you answered yes to any of the questions above, please provide further details to assist staff.
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
If you answered yes to any of the questions above, please provide further details to assist staff.
How did you hear about us?
*
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