Referral Form
Please complete the below relevant information
Name of Participant
*
First Name
Last Name
Name of Guardian (If applicable)
First Name
Last Name
Participant Date of Birth
*
/
Day
/
Month
Year
Date
Primary Diagnosis/Disability under NDIS Plan
*
As per Access Decision Letter
Is the participant verbal? Y/N
*
NDIS Plan Start Date
*
/
Day
/
Month
Year
Date
NDIS Plan End Date
*
/
Day
/
Month
Year
Date
Has this plan been received on or after 19/05/2025?
Yes
No
With the introduction of funding periods and components in NDIS plans, we now require confirmation of the hours available for each funding period. This helps us align our services with the plans structure and ensure continuity of support. Any unused hours within the funding period, ELEV8 will automatically roll over and apply to the next funding period to ensure continuation of services
Rows
Start/Finish date of each funding period
Amount allocated for this funding period
Funding Period 1
Funding Period 2
Funding Period 3
Funding Period 4
Address
Please provide the participants address
Street Address
Suburb
City
State
Please Select
ACT
NSW
QLD
NT
SA
TAS
VIC
WA
Postcode
Address of Participant
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Whose email is this?
*
Please Select
Participant
Support Coordinator
Guardian
Plan Manager
Phone Number
*
-
Area Code
Phone Number
Whose Phone number is this?
*
Please Select
Participant
Support Coordinator
Guardian
Plan Manager
Who is best to contact to schedule the initial appointment with?
*
Participant
Guardian
Support Coordinator
Plan Manager
Other
Please provide contact details if different to the above
Participant's NDIS Number
*
Are you Plan or Self-Managed (Please note we do not take on agency managed)
*
Plan Managed
Self Managed
Plan Manager Name - Please put N/A if Self Managed
*
First Name
Last Name
Plan Manager Email
example@example.com
Plan Manager Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Are invoices sent to the nominated plan manager above?
Please Select
Yes
No
If no, please provide name, email and phone number of who these will be sent to
Plan End Date
*
/
Day
/
Month
Year
Date
NDIS Goals (If known)
Support Coordinator details (Please note N/A if not using)
Support Coordinator Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Please select services you are referring for?
*
Occupational Therapy
Exercise Physiology
Physiotherapy
Counselling
Employment Support Services
Speech Pathology
One of our Occupational Therapists works alongside a certified assistance dog and currently has immediate appointment availability. Please indicate the client’s preference regarding the presence of the assistance dog during appointments.
*
Please Select
Comfortable with assistance dog present
Prefer appointments without assistance dog
The assistance dog is fully trained and certified and remains under the clinician’s supervision at all times. If the client prefers appointments without the assistance dog, appointments will be scheduled based on the next available Occupational Therapist capacity.
Please provide specifics around counselling services you require
Which OT Services which do require?
Category A Home Modifications Assessment
Assistive Technology Assessment
Functional Capacity Assessment
Ongoing Therapy Supports
Home and Living Assessment (SIL,SDA,ILO)
Report Due Date
*
-
Month
-
Day
Year
Please note: The requested report due date assists with triaging and clinician allocation. Timeframes will be confirmed once the referral has been reviewed and scheduled, subject to clinician availability and assessment requirements.
Which Physiotherapy Services which do require?
Functional Assessment
Assistive Technology Prescription
Manual Therapy and mobility support
Neurological Rehabilitation including Stroke Rehab
Ongoing Therapy Supports
Which Exercise Physiology Services which do require?
Exercise Plan and prescription
Cardiovascular Function
Exercise for Mental Health
Neurological Rehabilitation
Which Speech Pathology Services which do require?
Communication Assessment
Swallowing and Mealtime Management Assessment
Functional Capacity and Goal Setting Assessment
Ongoing Therapy Services
How many hours do you require for the service if already within your plan?
*
Preferred Appointment Time
Please Select
Morning
Afternoon
Flexible
Can services be delivered via telehealth?
*
Please Select
Yes
No
Flexible
Who is best to send the services agreement to?
*
Please Select
Support Coordinator
Participant
Participant's guardian/representative
Other
If you selected other, please provide email address for services agreement to be sent
Any other information you feel is relevant to let us know or in relation to the reason for referral. The more information you provide helps us allocate the most suitable clinician
*
Please upload current NDIS Plan - Please note this required to complete intake
*
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Please upload medical report/s in relation to diagnosis
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How did you hear about us?
Social Media
Search engine
Word of mouth
You have used our services before
Karista
Please let us know who referred you to our services, we would like to say thankyou
Other supports that may be relevant
As part of our multidisciplinary service model, ELEV8 can also assist with a range of allied health and vocational supports. Please indicate whether you would like us to consider whether any additional services may be suitable for this participant, subject to their goals, needs, and available plan funding.
Please select any additional services that may be relevant
Telehealth Counselling - Supports emotional wellbeing, adjustment, confidence and coping strategies. Often funded under Improved Daily Living or similar capacity-building supports.
Telehealth Speech Pathology - Supports communication, social interaction, swallowing, and functional language needs. Often funded under Improved Daily Living or Core supports where directly related to daily function.
Physiotherapy - Supports mobility, strength, pain management, physical function and independence. Often funded under Improved Daily Living, Health and Wellbeing supports, or Core supports depending on the participant’s plan.
Employment Consulting - Supports job readiness, vocational goal setting, workplace planning and employment pathways. Often funded under Finding and Keeping a Job or other employment-related capacity-building supports.
Occupational Therapy - Supports functional capacity, independence, sensory or cognitive strategies, equipment recommendations and daily living skills. Often funded under Improved Daily Living, Assistive Technology-related supports, or Home and Living supports depending on need.
Unsure, please discuss with me - ELEV8 can review the participant’s goals and support needs to help identify suitable multidisciplinary service options
No thankyou, nil other services required at this time
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