Services request

Name of Participant*

Given Name/sLast Name

Date of Birth*

Date

NDIS Participant Number*

Plan Start Date*

Date

Plan End Date*

Date

Address of Participant*

Diagnosis/es*

If school-aged please include school name & year level

Name of Guardian (if relevant)

First NameLast Name

Email*

example@example.com

Whose Email is this?*

ParticipantGuardianSupport Co-ordinator

Phone Number*

Please enter a valid phone number.

Whose Phone Number is this?*

ParticipantGuardianSupport Co-ordinator

Who is the best contact person to make the initial appointment with?*

ParticipantGuardianSupport Co-ordinatorOther

What Services are you interested in*

Ongoing Therapy (waiting list minimum 10 months)Functional Capacity AssessmentAssistive Technology Services

Plan Type - i.e. plan managed, self managed, agency managed. If Plan Managed please provide details*

Please provide NDIS Goals (if known)*

Support Co-ordinator Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Message/Reason for Referral. Please provide any relevant details

Attach files - NDIS Goals/ plan

Parent / Guardian Consent

As the authorised representative of this child, I consent to a referral to Helix Therapy Services. I understand that Helix Therapy Services may discuss the information contained in this form with relevant health professionals and educators in order to provide the most appropriate services for my child. I understand the attachments within the referral are accessed to only Helix Therapy Services team and consent to the information to be reviewed by the team

As the authorised representative of this child, I consent for the Occupational Therapist to inform the referrer of the assessment outcome and any other feedback relating to my child's communication concerns. I understand that I can choose to decline this consent at any stage by notifying the Occupational Therapist in writing.

I Agree to the Terms and Condition*

Yes

Services request

Support Co-ordinator details