Participant Referral & Consent to Engage

Participant Referral & Consent to Engage

Kindly fill out the form below. Please be aware that consent to proceed will be required in the final step.
Step 1: Your Details

Person Making the Referral
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Company Name*
YesNo
Reason for the Referral/ Relevant Medical Information? *
Step 2: Participant Details
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Gender*
YesNo
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PhoneEmailVisitOther
SDASILSTAOther
Primary Diagnosis*
Please provide clients primary diagnosis
Secondary Diagnosis*
Please provide clients secondary diagnosis
What are the requested support hours and days? (Please specify hours per day and per week)
Please provide weekly support hours and preferred days
YesNo
Is there any additional information you'd like us to be aware of, such as other relevant health conditions ?
Additional information will help with engagement with the client
Preferred Language
If the preferred language is not english
Do you require an interpreter?
Do you have any specific requirements for workers?
Does the client have any behaviour or known behaviours of concern?
Does the participant have a criminal history?*
If yes, please outline the criminal offence?
YesNo
If yes, please describe the behaviour?
OT / BSP / Other Supporting documents (multiple documents can be uploaded)

Cancelof
Step 3: NDIS Plan Information
NDIS ManagedPlan ManagedSelf Managed
NDIS number*
NDIS Plan Start Date*

MonthDayYear
Date
NDIS Plan End Date*

MonthDayYear
Date
Plan Manager Name*
Plan Manager email for invoices*
example@example.com
Is there a Plan Nominee? If yes, please provide details*
If there is no guardian or nominee, please write "No" please write "No"
For budgeting purposes, what is the NDIS Core Support funding available for the participant for this current plan period?
This will help us track and budget the clients funding for core supports
Upload NDIS Plan (Optional)

Cancelof
Please provide the date when you/participant would like the supports to start?*

MonthDayYear
Date
LinkedinWebsiteFacebookWord of MouthGoogleNDIS provider finderHousing HubOther
Step 4: Consent to Engage

Please ensure that you have received conformation verbally or in writing before signing this agreement
Please complete and sign this form to authorise engagement with Cedar Care on behalf of your client.

Rest assured, we will not share your personal information with anyone unless you have granted permission, or if the disclosure is required or authorised by law.

We kindly ask that you obtain permission to engage with the participant. Please provide the decision maker’s approval in the table below.

You have already filled out the participant details on this form. If you are not the participant but are their representative, plan nominee, or legally appointed decision maker, please sign in the section below.
ClientSupport CoordinatorPlan NomineeLegally appointed decision maker
Signature*

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Date*

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

Participant Referral & Consent to Engage

Step 1: Your Details

Step 2: Participant Details

Step 3: NDIS Plan Information

Step 4: Consent to Engage