Participant Details
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Gender
----
Female (she/her)
Male (he/him)
Non-binary (they/them)
Transgender
Gender Neutral
Prefer not to say
Is the participant...
Torres Straight Origin
Aboriginal
Culturally And Linguistically Diverse (CaLD)
None of these
Language
English
Interpreter required
Auslan
Assistive technology
Other
Email
Phone
Address
Primary Diagnosis/Disability
Secondary Diagnosis/Disability
Status
----
Married
Single
Defacto
Separated
Widowed
Divorced
Children
----
Yes
No
Living Situation
----
Living independently
Living with a carer or relative
Homeless
Other
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Guardian/Primary Carer Details
First Name
Last Name
Email
Phone
Relationship to participant
Address
Is this an emergency contact?
----
Yes
No
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Referrer Details
First Name
*
Last Name
*
Email
*
Phone
*
Organisation
*
Position
*
Address
How did you hear about Sunflower Services?
----
Support Coordinator
Caseworker
Local Area Coordinator
NDIS Provider Listing
Family/Friend
Facebook
Instagram
TikTok
Google
Bus
Billboard
Advertisement
LinkedIn post
Email Marketing
Other
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NDIS Details
NDIS Number
Plan Start Date
-
Day
-
Month
Year
Plan End Date
-
Day
-
Month
Year
Funding available in plan
Hours of support per week
Note: Sunflower Services has a standard minimum service requirement of one 2-hour shift per fortnight.
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Introduction to Participant
Which of our services does the participant require?
*
Support Work
Psychosocial Recovery Coaching
Support Coordination
Supported Independent Living
Individualised Living Option
Respite
Specialised Substitute Residential Care (SSRC)
Preferred Case Worker (optional)
Please Select
Tahlia Brien
Katie Chisholm
Calia Chourtos
Abigail Prentice
Jordy Lennon
Maddie Hardes
We’ll do our best to match you with your preferred team member, subject to current staff availability and operational requirements.
Preferred Psychosocial Recovery Coach (optional)
Please Select
Mylene Melliza
Alissa Hodges
Sophie Edwards
Allison Pinnock
Emily-Jane Whalley
Mia Ball
Tom Simpson
Kristen Olson
Katya Stuck
Aly Armstrong
Madison Riley
We’ll do our best to match you with your preferred team member, subject to current staff availability and operational requirements.
Preferred Support Coordinator (optional)
Please Select
Mylene Melliza
Alissa Hodges
Sophie Edwards
Allison Pinnock
Emily-Jane Whalley
Mia Ball
Tom Simpson
Kristen Olson
Katya Stuck
Aly Armstrong
Madison Riley
We’ll do our best to match you with your preferred team member, subject to current staff availability and operational requirements.
Is the Participant comfortable with virtual Meet and Greet?
----
Yes
No
General Information
Presenting Risks/Complexities
Is the Participant supported by only one worker?
----
Yes
No
What are the Participant's Short-Term NDIS goals?
What are the Participant's Long-Term NDIS goals?
Does the Participant have any allergies?
----
Yes
No
Does the Participant have any Health/Medical conditions?
----
Yes
No
Participant's preferred method of communication
Texting
Calling
Email
Other
Participant's living arrangements
----
SIL
OOHC
Living in own home with family or carer
Living in own home independently
ILO
Is the Participant at risk of choking, seizures, or anaphylaxis?
----
Yes
No
Is the Participant under Public Guardian?
----
Yes
No
Do not wish to disclose
Is the Participant under care of the minister?
----
Yes
No
Do not wish to disclose
Is the Participant under TAG (Trustee and Guardian)?
----
Yes
No
Do not wish to disclose
Plan nominee?
----
Yes
No
Do not wish to disclose
Is assistance with medication and medication administration required?
----
Yes
No
Do not wish to disclose
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Home Safety Risk Assessment
Is the home easy to locate?
----
Yes
No
Unknown
Is onsite parking available for support workers?
----
Yes
No
Unknown
Are there any slip, trip or falling hazards outside or inside the home?
----
Yes
No
Unknown
Is there a pet or pets?
----
Yes
No
Unknown
Is there poor phone reception at the home?
----
Yes
No
Unknown
Is there a clearly designated entrance and exit for staff to access the home?
----
Yes
No
Unknown
Is the Participant at risk of absconding?
----
Yes
No
Unknown
Does the Participant require a two-person visit for safety reasons?
----
Yes
No
Unknown
Are there any safety concerns Sunflower Services need to be aware of?
----
Yes
No
Unknown
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Final Steps
How is the participant managed?
----
Plan Managed
Self Managed
Agency Managed
Plan Manager name (if applicable)
Plan Manager email (if applicable)
Which office should we direct your referral to?
----
Newcastle (NSW)
Adelaide (SA)
Additional Comments
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Do you wish to join our email list to receive newsletters, uplifting stories, and updates on our services, including Supported Independent Living (SIL) and NDIS accommodation options?
----
Yes
No
Has the participant/guardian consented to this referral?
----
Yes
No
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