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
I have obtained consent from the participant to make this referral and provide Cedar Care with the participant's personal and medical details.
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
Can we contact the Participant directly?
Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of Communication?

Other
What supports are you looking for?

Other
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
Does the client have Restrictive Practice?
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?
Does the participant have a history of verbal or physical aggression?
If yes, please describe the behaviour?
OT / BSP / Other Supporting documents (multiple documents can be uploaded)

Cancelof
Step 3: NDIS Plan Information
Type a question
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)

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

MonthDayYear
Date
How did you hear about us?

Other
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.
I am:
Signature
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