ETT Referral Form

Empowered Therapy and Training Nationwide Referrals

ABN: 55 637 079 620
This referral must be actioned:*

UrgentlyWithin the next 2 weeksWaitlistOther
Client Details
Are you a:*

Private ReferralNDIS Participant
If you were referred privately, you are encouraged to complete 10 sessions at a time. Do you agree?

YesNo
Client/Participant Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Current Client Diagnosis (ASD, OCD etc)*

Next of Kin - Contact #1*


Name
Phone Number
Email Address
Home Address
Relationship to client/participant

Next of Kin - Contact #2*


Name
Phone Number
Email Address
Home Address
Relationship to client/participant

Invoice to*

First NameLast Name
Invoicee's Organization Name*
Invoicee's Phone Number*
Please enter a valid phone number.
Invoicee's Email*
example@example.com
NDIS Participants Only
Participant Number*
Plan Type*

NDIS-managedPlan-managed (organisation-managed)Self-managedOther
Plan Start Date*

DayMonthYear
Date
Plan End Date*

DayMonthYear
Date

Short-term Goals*
Long-term Goals*
Supports Required
Therapeutic Supports

Art TherapyCounsellingPsychotherapyMusic/Movement TherapyDietitianSpeech TherapySandplay TherapyDrumming TherapyLaughter TherapyHypno-therapyTimeline TherapyDrama TherapyNeurolinguistic Programming (NLP)Other
Group Activities

Day-Group Adventures:Activities like movie outings, museum visits, science adventures, and more.Day-Group Camps:A 10-week program to make new friends and engage in activities like feeding animals, horse riding, cooking, drawing, and movement classes.Girl Pampering WeekendsBoys to Men WeekendsASD Autism Weekends
Accommodation

Assistance with Accommodation and Tenancy ObligationsAssistance with Coordinating or Managing Life Stages, Transitions and SupportsAssistance with Daily Life Tasks in a Group or Shared Living Arrangement including Supported Independent Living (SIL) and/or RESPITEParticipation in Community, Social and Civic Activities (see activities below)Group and Centre Based Activities (see activities below)Other
If you would like to request supports for Home and Living, for example if you would like assistance to find accommodation (short or medium term), please fill out the following form after you have submitted the current referral form.

https://form.jotform.com/empoweredtherapy/request-for-home-and-living-support
Education

Life-skills learning program (adults and children)School of Life ProgramsAdult learning programsSchool-aged learning programsOther
If you would like to request supports for any education program, please fill out the following form after you have submitted the current referral form.

https://form.jotform.com/empoweredtherapy/kool-kids-camp-enrolment-form-filla
Assessments

Behaviour Support (includes Positive Behaviour Support Plans)Mental, Social, Emotional, Behavioural, Cognitive AssessmentOther
If you would like to request supports for any formalised assessments , please fill out the following form:

https://form.jotform.com/empoweredtherapy/ett-formalised-assessments-registra
Employment/ Higher Education

Access and Maintain Employment or Higher EducationSpecialised Support EmploymentOther
Other

Early Childhood SupportsOther
Events (Face to Face or Online)
Half-day Events

Understanding the Children of TodayParent-Child ConnectionManaging Stress and Emotions for TeenagersDomestic Violence AwarenessUnderstanding and Living with AutismBecoming a Life-skills TeacherWho am I? A Journey to Reconnect with One's SelfMind-setting - if you change your thoughts, you change our life
Full-day Events/ Retreats

Understanding the Children of Today and Parent-Child Connection Bootcamp (3 days)Understanding and Living with AutismHow NOT to Mess Your Child's Life - Parents/Carers/Teachers LifeMind-setting - if you change your thoughts, you change your life (advanced level, 3 day retreat)Who am I? (advanced level, 3 Day retreat)
Workshops (for individuals, corporate and private organisations)

Girls' Pamper - self care, self worth day programFrom Boys to Men - self care, self worth day programLaughter WorkshopDrumming WorkshopLaughter and Drumming WorkshopDomestic Violence WorkshopOther
Train the Trainers (opportunity to become qualified facilitators and to gain potential employment)

Authentic Professional Speaker's Course (online and FTF) - learn to become a professional facilitator (2.5 day training)Laughter Facilitator (2 days)Drumming Facilitator (2 days)
Camps

Self-esteem school-aged campsResilience school-aged campsParent and child connection camps
If you would like to enrol in any of our camps, please fill out the following form:

https://form.jotform.com/empoweredtherapy/kool-kids-camp-enrolment-form-filla
What specific line item supports your budget (Example - 04_104_0125_6_1)*
I want to know more about your events*

YesNo
Any further information you would like us to know:
Upload past assessments, reports and/or your NDIS plan here.

Cancelof
Files attached (see previous question and tick all that apply)

Past Assessment(s)Past Report(s)NDIS PlanOther
NDIS Support Categories and Support Item Numbers
Should be Empty:

	$
Therapies
Plan Management
Support Coordination
Support Work
Transport
Equipment
Camp
Programs (see below)
Group-based activities
Other

Empowered Therapy and Training Nationwide Referrals

Client Details

NDIS Participants Only

Supports Required

Events (Face to Face or Online)