NDIS Art Therapy Intake & Referral Form
Thank you for reaching out to Louisa Chan Creative! Please use this safe and secure form to request Art Therapy services in the Ryde and Greater Sydney area. We review all submissions within 24 business hours and look forward to connecting with you.
💬 Section 1: Who is filling out this form?
I am completing this form as:
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Support Coordinator or NDIS Navigator
Parent, Guardian, or Carer
Participant (Self-Referral)
Other Allied Health Professional (e.g., OT, Case Manager)
Your Full Name
*
First Name
Last Name
Organisation / Company Name
If you are a Coordinator or Professional
Your Email Address
*
This is where we will send our reply
Your Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
👤 Section 2: Participant Information
Participant's Full Name
*
First Name
Last Name
Participant's Date of Birth
*
 -
Day
 -
Month
Year
Date
Suburb of Residence
*
To help us plan our travel if you request mobile visits
Who should we contact to schedule sessions?
*
Contact the participant directly
Contact the parent/guardian/carer
Parent/Guardian/Carer Name & Phone
💰 Section 3: NDIS Funding Details
This helps us make sure your invoicing is set up correctly right from the start.
NDIS Participant Number
*
9-digit identifier
How is the NDIS budget managed?
*
Plan-Managed (A third-party company pays the invoices)
Self-Managed (The family or participant pays the invoices directly)
Name of Plan Management Company
If Plan-Managed, e.g., Plan Partners, Leap In!
Email address for invoice delivery
*
example@example.com
🎯 Section 4: Goals & Support Needs
What goals would you like to work on through Art Therapy? (Tick all that apply)
Emotional Regulation & Managing Sensory Overload
Confidence, Self-Esteem & Communication
Fine Motor Skills & Coordination
Social Skills & Connecting with Community
Building Independence & Decision-Making
Where would you prefer sessions to take place?
*
Mobile (At home, school, or a day program around Sydney)
In the Art Therapy Studio
Is there anything else you would like us to know?
Please share any specific support needs, interests, or helpful safety details.
Submit Intake Form
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