Support Work - Referral Form

Support Work - Referral Form
Participant Details
Participant Name

First NameLast Name
Date of Birth

DayMonthYear
Date
NDIS Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of contact:
Communication channels:
Please complete if the participant is under 18 years of age, has a Public/Legal Guardian or Representative, has a Plan Nominee
Parent / Legal or Public Guardian / Representative / Plan Nominee

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referrer Information
Referrer Name

First NameLast Name
Role/Relationship
Company
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Diagnosis Information
Diagnosis
Support Information
Services required as outlined in NDIS Plan:
PLEASE NOTE:

24/7 Supports - charged at base rate of $98.32

- Assistance with Daily Life

- Access to Community & Community Participation

*Additional codes and charges apply for week nights, weekends, public holidays, sleepover supports and transport

Monday to Friday ONLY supports - charged at $112.08

- Skills & Development

- Finding & Keeping a Job / Employment Assistance

- Increasing Social & Community Participation

*Support times limited to 12am - 12am Monday to Friday. Additional code for transport applies charged at $1 per KM.
Days participant requiring supports:
If certain times required for supports, please list below:
Does the participant's funding cover public holiday supports?:
PLEASE NOTE

The following support categories do not allow for supports on public holidays:

- Skills & Development

- Finding & Keeping a Job / Employment Assistance

- Increasing Social & Community Participation

If supports fall on a public holiday and/or no funding is allocated for these to occur, we will endeavour to discuss alernative days we can provide supports or the supports will be cancelled if no altenative options are available.
Preference for support worker
Are there any requirements / skills / training that is required the support worker have?:
Examples: support required to be epilepsy trained; or must be interested in gaming/fishing; or has skills in art/theatre/woodwork
Outline of Supports Required:
NDIS Goals to be achieved through this referral:
Medical Considerations
Are there any Medical considerations we must know about?:
Does the participant take regular medications we need to be aware of?:
Please list Medications:
Behaviour Support

If a participant is receiving Behaviour Support and/or has a Behaviour Support Plan, it is important that support workers are appropriately trained, ensuring that we are delivering supports in adherence to the plan and to maintain NDIS Compliance standards.
Is there currently a Behaviour Support Plan in place?:
Behaviour Support Plan

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Are there Restrictive Practices in place?:
Type of Restrictive Practice:
Please provide details of Restrictive Practice
Please note: This is asked for informative purposes only. As we are still working towards obtaining our NDIS registration, our support team is unable to administer any restrictive practices.
Does Haven Therapeutic Services provide Behaviour Support to this participant?:
Haven Practitioner Name:
If Haven does not provide Behaviour Support, please provide Practitioner Details

First NameLast Name
Company:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Any other information you feel we may need to know
NDIS Plan & Other Relevant Reports
Please attach NDIS Plan & Other Relevant Reports etc:

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Funding Allocation Information
Total hours to be allocated:
Total funding amount to be allocated:
If hours / funding allocation to be split between multiple support categories, please outline allocation (if not applicable - type N/A):
How is the participants funding managed:
As we are working towards obtaining our NDIS registration, we are unable to provide supports to participants that are NDIA managed at this time
Plan Manager or Name of Payee:
Email Address for invoices to be sent:
Should be Empty:

Support Work - Referral Form

Participant Details

Please complete if the participant is under 18 years of age, has a Public/Legal Guardian or Representative, has a Plan Nominee

Referrer Information

Diagnosis Information

Support Information

Medical Considerations

Behaviour Support

Any other information you feel we may need to know

NDIS Plan & Other Relevant Reports

Funding Allocation Information