Referral Form
Please complete this form when making a referral to Prime Care Access.
Participant First Name
*
Preferred Name (if different from legal first name)
Participant Last Name
*
Participant Date of Birth
*
-
Day
-
Month
Year
Date
Participant Gender
*
Please Select
Male
Female
Other
Prefer Not To Say
Participant Email
example@example.com
Does the participant have a phone number?
*
Please Select
Yes
No
Participant Phone Number
Please enter a valid phone number.
Participant's Preferred Method of Communication
*
Please Select
Telephone
Email
Text / SMS
All / Any
NDIS Number
*
NDIS Plan Start Date
*
-
Day
-
Month
Year
Date
NDIS Plan End Date
*
-
Day
-
Month
Year
Date
Current Living Arrangements
*
Please Select
With Others
Alone
With Family
Hospital
Participant Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Culture and Language
Please tell us about the participant's culture and language requirements.
Participant Country of Birth
*
Participant First Language
*
Participant Second Language (if applicable)
Does the participant require a translator?
*
Please Select
Yes
No
Does the participant have any culture, diversity, values and beliefs of which we should be aware?
*
Please Select
Yes
No
Culture, Diversity, Values and Beliefs
Disabilities
Please select Yes or No for each possible disability - there is room for further diagnosis and medical detail after this.
Autism
Please Select
Yes
No
Brain Injury
Please Select
Yes
No
Cerebral Palsy
Please Select
Yes
No
Developmental Delay
Please Select
Yes
No
Down Syndrome
Please Select
Yes
No
Epilepsy
Please Select
Yes
No
Global Developmental Delay
Please Select
Yes
No
Hearing Impairment
Please Select
Yes
No
Intellectual Disability
Please Select
Yes
No
Multiple Sclerosis
Please Select
Yes
No
Psychosocial Disability
Please Select
Yes
No
Spinal Cord Injury
Please Select
Yes
No
Stroke
Please Select
Yes
No
Visual Impairment
Please Select
Yes
No
Diagnosis / Medical Conditions
Please enter any other relevant diagnosis, disability, or medical information.
Tell us about the participant's diagnosis and medical conditions
*
Does the participant have any regular allied health appointments?
Allergies
Please select Yes or No for each possible allergy - there is room for further allergy detail after this.
Drug Allergy
Please Select
Yes
No
Food Allergy
Please Select
Yes
No
Insect Allergy
Please Select
Yes
No
Latex Allergy
Please Select
Yes
No
Mould Allergy
Please Select
Yes
No
Pet Allergy
Please Select
Yes
No
Pollen Allergy
Please Select
Yes
No
Tell us more about your allergies (if applicable)
Behaviour Support Plan
Does the Participant have a Behaviour Support Plan?
*
Please Select
Yes
No
Is the Participant Physically Abusive?
*
Please Select
Yes
No
Are there Restrictive Practices in the Behaviour Support Plan?
Please Select
Yes
No
Behaviour Support Practitioner - Organisation Name
Behaviour Support Practitioner Full Name
First Name
Last Name
Behaviour Support Practitioner - Email
example@example.com
Behaviour Support Practitioner - Phone Number
Please enter a valid phone number.
Behaviour Support Plan - Upload
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Reports
Please upload any relevant Allied Health reports such as OT, Speech Therapy, Psychologist etc
Allied Health Reports - Upload
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Ratios, Gender, and Age Preferences
Preferred Gender of Support Workers
*
Please Select
Male (only)
Female (only)
Don't Mind
Minimum Age of Support Worker
*
Enter your preference
Maximum Age of Support Worker
*
Enter your preference
Support Requirements
Please let us know what supports are required for each category. There is a separate section for shift start and end times after this.
Personal Care
*
Please Select
Yes
No
Does the participant require support with Personal Care?
Personal Care Support
Mobility
*
Please Select
Yes
No
Does the participant require support with Manual Handling?
Mobility Support
Transfers
*
Please Select
Yes
No
Does the participant require support with Transfer?
Transfer Support
Domestic Assistance
*
Please Select
Yes
No
Does the participant require support with Domestic Assistance?
Domestic Assistance Supports
Community Participation
*
Please Select
Yes
No
Does the participant require support with Community Participation?
Community Participation Supports
Mealtime Management
*
Please Select
Yes
No
Does the participant require support with Mealtime Management?
Mealtime Management Supports
Communication
*
Please Select
Yes
No
Does the participant require support with Communication?
Communication Supports
Medication Management
*
Please Select
Not Required
Prompting
Assisting
Administering
Unsure
Medication Management Supports
Informal Supports
*
If informal supports via friends, family, neighbours are in place, please include details here.
Services Required
Tick all that apply
NDIS - Services Required
Severe Dysphagia Support
Complex Bowel Care
NeuroAdmin Ally
Personal Care / Assistance With Daily Living
Community Nursing Care
Community Participation
Respite Support
Post Hospital Care
Travel/Transport
Goals & Interests
Now please let us know about the participant's goals.
How Do You Want To Tell About Goals?
Please Select
Refer to NDIS Plan for Goals
Tell You More
Short / Medium / Long-Term Goals
Hobbies and Interests
*
Power of Attorney
A Power of Attorney is a legal document that gives a person, or trustee organisation the legal authority to act for you to manage your assets and make financial and legal decisions on your behalf.
Does Power of Attorney Apply to the Client?
*
Please Select
Yes - Enduring Power of Attorney
Yes - General Power of Attorney
No
Who is the Participant's Attorney?
Please Select
Family Member
Friend
Solicitor
Office of the Public Guardian (NSW)
Attorney Organisation Name
Attorney Full Name
First Name
Last Name
Attorney Email
example@example.com
Attorney Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Power of Attorney Proof Upload
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Nominee
Guardians are not nominees under the NDIS and there is no automatic process for guardians to be made nominees (although sometimes the Guardian and Nominee end up being the person or organisation)
Does the Participant have a Nominee?
Please Select
Yes - Plan Nominee and Correspondence Nominee (combined)
Yes - Plan Nominee (only)
Yes - Correspondence Nominee (only)
No
Nominee First Name
Nominee Last Name
Nominee Email
example@example.com
Nominee Phone Number
Please enter a valid phone number.
Nominee NDIA Instrument of Appointment - Upload
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Guardianship
Guardianship allows the Guardian to make decisions about your health and daily care in the event you can't make those decisions. If you have a Guardian, they make decisions about matters such as where you live and the services you might receive, healthcare, medical and dental treatment.
Does Guardianship Apply to the Participant?
*
Please Select
Yes - Enduring Guardian
Yes - Public Guardian
No
Who is the Participant's Guardian?
Please Select
Family Member
Friend
Office of the Public Guardian (NSW)
Guardian Organisation Name
Guardian First Name
Guardian Last Name
Guardian Email
example@example.com
Guardian Phone Number
Please enter a valid phone number.
Guardian Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardianship Proof Upload
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Support Coordinator
Does the participant have a Support Coordinator?
Please Select
Yes
No
Support Coordinator Full Name
First Name
Last Name
Support Coordinator Email
example@example.com
Support Coordinator Phone Number
Please enter a valid phone number.
Plan Manager
Is the participant Plan Managed?
*
Please Select
Yes
No - Agency NDIA Managed
No - Self Managed
For Steadway's services that will be billed.
Plan Manager - Organisation Name
Plan Manager - Invoices Email Address
example@example.com
Plan Manager - Phone Number
Please enter a valid phone number.
General Practitioner
GP - Organisation Name
GP - First Name
GP - Last Name
GP - Email
example@example.com
GP - Phone Number
Please enter a valid phone number.
GP - Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who shall we speak to about this referral?
Referring Full Name
*
First Name
Last Name
Referring - Email
*
example@example.com
Referring - Phone Number
*
Please enter a valid phone number.
Final Important Notes
Are there any further important notes that need to be communicated?
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