• Participant Referral & Intake Form

    We specialise in SIL and ILO supports, with experience transitioning young people from OOHC to NDIS SIL. Not sure we're the right fit? Contact Josh first: josh@lifeheart.com.au | 0405 061 741. This form is detailed — you can save your progress and return later.

  • 1. Referral Details

  • Date of referral*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
  • Will you be the primary contact person for the participant?*

  • 2. Participant Details

  • Date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
  • Does the participant identify as Aboriginal and/or Torres Strait Islander?
  • Is an interpreter required?*
  • Preferred format for written information*
  • Current living situation

  • 3. Legal & Decision-Making

  • Does the participant have a formal substitute decision-maker?*
  • Does the participant or their family have any personal, family or business relationship with any Lifeheart worker or key personnel?
  • Are there any current legal orders? (guardianship, CTO, AVO, justice/forensic, child protection)*
  • How is the participant's NDIS funding managed?*

  • 4. NDIS Information

  • Does the participant have an active NDIS plan?*
  • Plan start date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Plan review/renewal date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Support purposes to utilise*
  • Support categories to utilise*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • 5. Housing & Tenancy

  • This referral relates to:*
  • Is the dwelling Specialist Disability Accommodation (SDA)?
  • Is there a separate tenancy/accommodation agreement in place?
  • Will the participant be moving into an established shared house?
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Is Lifeheart or a related party the housing or tenancy provider?
  • Requested support ratio*
  • Overnight support type required*
  • Requested support start date
     - -
    2 digit day, 2 digit month, 4 digit year

  • 6. Risk & Safety

  • Requested support schedule (we will try our best to accommodate)
    Rows
  • Are any restrictive practices currently in place or previously authorised?*
  • Type of restrictive practice
  • Authorisation status
  • Classification of restrictive practice(s) in use
  • How is each restrictive practice used?
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Behaviour Support Plan review/expiry date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Is an interim Behaviour Support Plan required (immediate behaviour support need with no current plan)?
  • Any history of emergency or unauthorised restrictive practice use?
  • Does the participant have a Behaviour Support Plan (BSP)?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • History of behaviours of concern (e.g. aggression, property damage)?*
  • History of self-harming behaviour?
  • History of substance misuse?
  • Is the participant currently receiving mental health treatment or support?*
  • Please tick any that apply:*

  • 7. Functional Needs

  • Primary communication method*
  • Level of support needed for daily activities (1 = Independent, 2 = Prompting only, 3 = Partial assist, 4 = Full assist)
    Rows
  • Sensory sensitivities we should know about?*
  • Does the participant require manual handling (e.g. hoist, slide sheet)?*
  • Home environment / worker safety factors

  • 8. Medical Information

  • Ambulance cover?
  • Any allergies?*
  • Does the participant take any medications?*
  • Does the participant require medication management from us?
  • Medication details
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Is an allergy/anaphylaxis plan in place?
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Medication assistance level
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Any swallowing concerns or dysphagia?*
  • Can the participant call 000 unassisted?
  • Does the participant require a Mealtime Management Plan?*
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Does the participant require any high-intensity supports?*
  • Any first aid requirements we should prepare for (e.g. seizure protocol)?*

  • 9. Emergency Contacts & Planning

  • Does the participant need assistance to evacuate in an emergency?*

  • 10. Allied Health & Support Network

  • Do you consent for Lifeheart to contact allied health providers?*
  • Do you consent for Lifeheart to request a handover from the previous provider?
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • 11. Participant Interests & Goals

  • 12. Referral-Stage Consent & Declaration

  • The participant / their representative consents to Lifeheart:*

  • This covers the referral stage only — full informed consent is confirmed with the participant at intake. By submitting, you confirm you have authority to provide this information under the Privacy Act 1988 and that it is accurate to the best of your knowledge. Consent can be withdrawn at any time. Information may be stored or processed overseas by our secure software providers.

  • Should be Empty: