Aligned Assist NDIS Referral Form

Aligned Assist NDIS Referral Form

Thank you for your interest in Aligned Assist Support Services! Please complete the secure intake referral form below. A team member will contact you within 1-2 business days to discuss the next steps. If urgent please also reach out to the team via info@alignedassist.com.au/ 1300 927 248 This form is fully encrypted to ensure your privacy, and all information provided will be used solely for intake and service coordination. We manage all personal data in compliance with the Privacy Act 1988 and our Referral Terms and Conditions. We look forward to supporting you on your journey!
- Please provide your details as the person making the referral.
- Your Full Name
  
  First NameLast Name
- Your Phone Number
  
  Area CodePhone Number
- Your Email Address
  example@example.com
- Your Organization (if applicable)
- Are you an authorised Representative/Nominee forthis Participant?
- Relationship to Client
- Do you have consent from the person (or their representative) that you are referring, and to disclose and share the information in this form?
- How Did You Hear About Us?
- Please provide details about the person being referred.
- Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  DayMonthYear
  Date
- Gender
- Mobile Number
  
  Area CodePhone Number
- Preferred Pronouns
- Email Address
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Is the participant of First Nations Origin?
  
  Other, Please describe below
- Marital Status
- Ethnicity
- Languages Spoken
- Will an Interpreter be required? If yes, what language?
  
  If Yes add further details below
- Please select your preferred contact method
  
  Other - Please add details below if not listed
- Are there any cultural or religious considerations that you would like us to know?
  
  If Yes add further details below
- NDIS Details
- NDIS Plan Number
- NDIS Plan End Date
  
  MonthDayYear
  Date
- NDIS Plan Start Date
  
  MonthDayYear
  Date
- NDIS Plan Management Type
- Plan Manager Company (If Plan Managed)
- Plan Manager Contact person (If Plan Managed)
- Email for invoices (If Plan Managed)
- Please attach NDIS Plan or Goals below.
  
  Cancelof
- Please provide detailed information about the participant's disability and medical history to assist with appropriate service coordination.
- Services Required
- When do you want to commence support?
  
  DayMonthYear
  Date
- Does the Participant require support to communicate?
  
  If Yes add further details below
- Does the Participant require a support person to be present during appointments?
- Who would be the best person to contact to book an appointment? If not the participant, please provide the name, date, time and contact details of the participant's representative that we will contact
- Support Schedule Preferences (Day and time)
- What is the participant's NDIS approved Disability/disabilities, please include Medical and/or Disability History ?
- Support and Care Needs Overview including preferences
- Do you have any of the following care plan?
- Current Supports Engaged
- Please list any relevant Providers, Medical Professionals, GP, Allied Health Professionals, NDIS Support Coordinators, NDIS Plan Management Agencies involved in the participants care. Please list below those that you allow us to contact, anyone else consent will be gained beforehand:
  1. Support Coordinator: 
  Name-
  Company Name-
  Mobile Number-
  Email Address- Support coordinator, Psychologist, GP, Hospital point of contact, support provider, etc.
- Primary/ Emergency Contact
- Name (Emergency Contact)
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Relationship
- Email Address
- Guardian/ Plan Nominee (If Applicable)
- Name (Emergency Contact)
  
  First NameLast Name
- Phone Number
  
  Area CodePhone Number
- Relationship
- Email Address
- Are there any risks to the Participant that you are aware of? If YES, please describe:
- Does the participant have a history of aggression and violence towards others, including caregivers and therapists?
  
  If Yes add further details below
- Does the participant have a diagnosed mental illness?
  
  If Yes add further details below
- Are there people other than the Participant and theirsupports on the premises during support? If Yes, please outline who
  
  If Yes add further details below
- Are there any requirements for access, such as a gatedpremise/community, dirt road, or specific directions requiredto access the property?
  
  If Yes add further details below
- If you are taking regular medication, please list:
- Does the participant collect/hoard items in their room/house?
- If so, do the collected items pose a potential fire risk?
- Does the participant smoke?
- If you smoke, do you smoke inside the home?
- Does the participant have a history of substance abuse (illicit drugs/alcohol)?
  
  If Yes add further details below
- Does the participant currently engage in substance
  
  If Yes add further details below
- Can the participant effectively communicate their wants and needs to others?
  
  If No add further details below
- Does the participant currently engage in or have a history of self-injurious behaviours/self-harm?
  
  If Yes add further details below
- Is the behaviour of the participant unpredictable? if so, please list details below in challenging behaviours
  
  If Yes add further details below
- Is there access or likely access to weapons on the premises?
  
  If Yes add further details below
- Do you have any pets?
  
  If Yes add further details below
- Are there any behaviours of concern or previous incidents with the participant that we should be aware of, that may cause potential harm by way of physical or verbal assault, inappropriate sexual and/or aggressive behaviours towards staff or clinician? If yes, please provide more information
  The health and safety of our staff and clinician is taken very seriously. As such, we have the right to refuse a service or decline a referral which lists behaviors of concern/other safety issues which may cause potential harm to the team. Please ensure that you complete this section honestly and provide as much information as possible to enable us to service the participant adequately.
- Before we start supporting _________, we’ll contact you as the referrer to get some more information. Is there anything else important that we need to know at this time?
- By submitting this form you acknowledge and declare that you have spoken with the client/their guardian regarding engaging our services, all the information provided above are correct and they are aware that you are submitting this referral on their behalf.
Should be Empty:

Aligned Assist NDIS Referral Form

NDIS Details

Current Supports Engaged

Primary/ Emergency Contact

Guardian/ Plan Nominee (If Applicable)