• Journey Community Connections ABN 98 666 694 293      

     Client Referral Form

  • Journey Community Connections appreciates that everyone is unique, please help us to get to know you by answering the following:

  • Client Date of Birth
     / /
  • NDIS Funding Type
  • Preferred Contact Method

  • Representative or Emergency Contact Details

  • Format: (000) 000-0000.
  • Preferred Contact Method

  • About You

    Living Situation
  • Aboriginal or Torres Strait Islander descent?
  • Does the Client have a Current Behavioural Support Plan?

  • About You

    Communication
  • Type of Communication?
  • Are you of a culturally or linguistically diverse background?
  • Do you have any culture, diversity, values and beliefs of which we should be aware?
  • Do you Require an Interpreter?

  • Preferred Worker Characteristics

    What do you wish to see in your Support Worker?

  • At Journey Community Connections, We recognize the significance of matching the right staff member to meet your needs and consider several factors such as personality, language, culture and skill requirements.

    We encourage and support you to be involved in the process of matching your needs with the right staff. We can also support you to access an advocate of your choice to support you in this process.



  • Gender

  • Please sign below to indicate your consent and agreement to the details set out in this client intake form above.

  • Signed for and on behalf of Journey Community Connections Pty Ltd ABN 98 666 694 293 (Journey Community Connections), by:

  • Date
     - -

  • Signed by the Client

  • Date
     - -

  • Signed by the Representative

  • Date
     - -
  •  

  • Approved By: The Board of Journey Community Connections Pty Ltd Approval Date: September 2025

  • Should be Empty: