NDIS_Referral_Form_The_Potters

NDIS Referral & Intake Form - The Potter's Reset (Helene Pouwels - ABN 18 249 081 898)

1. Participant Information
Full Name
Preferred Name (if different)
Date of Birth

MonthDayYear
Date
NDIS Number
NDIS Plan Type (Self / Plan / NDIA Managed)
Plan Manager (if applicable)
Plan Manager Email
Plan Manager Phone
Format: (000) 000-0000.
Support Coordinator Name & Contact Info
Participants Address
Participant's Email
example@example.com
Participant's Phone Number
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
2. Referrer Details (if not self-referred)
Referrer Name
Organisation
Role
Email
example@example.com
Phone
Format: (000) 000-0000.
Relationship to Participant
3. Respite Goals & Suitability
Why would you like to access respite at The Potter's Reset?
What are your goals or expectations for this stay?
Are there particular creative activities youre interested in pottery art walking gym etc
Do you require support with any daily tasks? (Please note: We do not offer personal care or mobility assistance).

Our space is not wheelchair accessible. Are you comfortable with stairs, uneven terrain, and low-level supports?

4. Health, Safety & Medical Info
Medical conditions, diagnoses, or relevant history:
Allergies or Dietary requirements

VegetarianVeganGluten-freeDairy-freeNut allergyDiabetic-friendly mealsOther
Is there a risk of anaphylaxis?

YesNo
If Yes, please attach an allergy or emergency care plan.
Meal preference during your stay

I prefer to eat meals prepared at the cottageI'd like to eat out at local cafes / restaurantsA mix of both
Do you have a medical clearance for travel and overnight stays, if applicable?
5. Preferences & Support Notes
Are there any emotional, sensory, cultural, or communication preferences we should be aware of?
What helps you feel safe calm and supported in a new environment?
Would you like access to optional recovery coaching sessions during your stay?

YesNoMaybe
Activities participant is interested in:

PotteryNature walksExploring waterfallsFire pit relaxationWatching moviesCookingUsing the GymLocal markets (when possible)Healesville SanctuaryOther
Are there any restrictions or preferences we should be aware of?
Animal comfort level:

Love animalsOkay with animals nearbyPrefers no contact
(Our property has alpacas, sheep, chickens, and friendly dogs. Animals can be kept separate with gated access if needed.)
Accomodation preferences:

Queen bedDouble bedKing Single bed
Do you have a companion card for supported access to activities?

YesNo
6. Consent
Do you give consent for photos/videos to be taken during the stay for internal use or marketing?

YesNoOnly with approval
Is a medical clearance or allergy plan available if needed?

YesNo
Date

MonthDayYear
Date
Name
Signature
Ideal Check in Date for the respite:

MonthDayYear
Date
Ideal of Length of Stay (in days)
Should be Empty: