Service Request Form WONDERLAND

About Wonderland's Services

Wonderland Community Services Pty Ltd is a registered NDIS Provider: 4050042146

Wonderland is committed to a holistic service for our participants meaning we want to improve the whole experience of our participants in their life working with family, friends and other network supports.

In our accommodation and care services we always look to build the capacity of our participants and consider the reality of the day to day practical needs of our participants. As well as our Short Term Accommodation and respite service Wonderland Retreat we also have:

* Wonderland Hideaway - Medium Term Accommodation - 2 - 12 weeks and SIL Supported Independent Living.

* Wonderland Care - In-home support

* Wonderland Club & Wonderland Adventures - Social, community and recreation activities

* Wonderland Day Program - great activities and outings to build skills and friendships

We also offer a Support Coordination Service.

Learn more about these creative initiatives on our Wonderland Retreat website.

www.wonderlandretreat.com.au

Let us know if we meet your expectations! We hope we do and exceed them as well.

Toni Mehigan - Director

NDIS Service Request

Referral Date

Date

Who is filling in this form?

Participant Name

First NameLast Name

Date of Birth

Date

NDIS Number

Current NDIS Plan

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Guardianship

Guardianship Type

Guardian Name

Guardian Phone

Guardian Email

example@example.com

Participant Address

Participant Phone (if appropriate)

Area CodePhone Number

Participant Email (if appropriate)

example@example.com

Coordinator of Support (COS) Name

First NameLast Name

COS Phone

Area CodePhone Number

COS Email

example@example.com

COS Organisation

COS Organisation Address

Street Address

Street Address Line 2

CityState

Post Code

Current Additional Service Providers

About the participant

Diagnosis

Medical Condition

Date

How can we help?

Further Diagnostic Information

What is the participant's current COVID-19 vaccination Status?

Other

Please attached a copy of the participant's COVID-19 vaccination certificate

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Current Medications

Please outline what each medication is for.

Are the medications listed used for a diagnosed physical or mental health disability? (ADHD & Autism are considered neurodevelopmental physical disorders.)

Are the medications listed used for Chemical Restraint?

If the answer to the question above is "YES", please specify.

(please advise which medications)

Most Recent Doctor's Orders

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Send these later if you don't have them now

Professional Reports including any Meal Management Plan/Medical Plans

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Please provide any existing professional reports you can send this later if you don't have them now

Does the participant has a companion card

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If yes, please upload a copy of it

Existing Services with our Organisation

Does the participant have any of the following?

If the participant has a Behaviour Support Plan please name the practitioner and provide their contact details.

Tell us what else we are doing for you currently or what we have done for you in the past.

Participants Main Goals

Participants Particular Health & Support Needs

Participants Interests, values & beliefs

Please provide as much information as possible so that we can support these areas well.

Participants language support needs including English as a second language and ethnicity

Please provide as much information as possible so that we can support these areas well.

Participants Preference (Eg: Preferred Age and Gender of the Support Worker)

Other Important Information we should know?

Is there any conflict of interest with any staff member of Wonderland CS that we should know about or other participants?

Referrer's Email

example@example.com

Role/ Relationship to Participant

Signature

Version date 08.01.2024

Wonderland Service Request

Demographic Information

CARE PLANNING INFORMATION