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Refer a client

Refer to a participant/a client/a patient/a friend/someone you know.

Fill out the details below and submit it online.

" * " indicates required fields.

Referral Date (DD/MM/YYYY)

1. Participant Details

Title

Firstname *

Surname *

Preferred Name

Gender

DOB (DD/MM/YYYY) *

Home Address *

Postal Address (If different from above address)

Email address * (Participant/Representative) )

Phone No.

Mobile No.

Cultural Background

Preferred Language

Interpreter Required

Yes

Aborginal or Torres Strait Islander

Yes

NDIS Number

NDIS Start Date

NDIS End Date

Participant's NDIS Type

Self Managed

Plan Managed

NDIS Managed ( A copy of the NDIS plan MUST BE provided for NDIS managed participants )

Invoicing Details

Name

Preferred option for communication

Phone number

Address

2. Primary / Emergency Contact Details

FullName *

Phone no. ( Other than above if applicable )

Relationship

Parent

Guardian

Caregiver

Other ( Please specify )

Home Address

Email Address

Lives with participants

Yes

Preferred method of contact

3. Healthcare Information

Medication Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

4. About The Participant ( Other Details )

Living Situation:

Type Of Disability

Primary Disability *

Other Disability

Religious / Cultural Req.

Does the participant have a current behavioural support plan ( BSP ) ?

Yes

If yes, please provide the details of behaviour practitioner & attach details.

Practitioner's name

Contact number

Address

Medical condition / diagnosis & any allergies:

Mobility:

Others

Communication:

Verbal

Non-verbal

Aids

Others ( Specify )

Visually Impaired ?

Yes

Comments

Dietary Requirements ?

Yes

Comments

Swallowing Difficulties ?

Yes

Comments

Services Required *

( eg. Personal Care, Household Tasks, Nursing, Community Participation etc. )

Care Preferences

( eg. Male, Female and skills required. )

5. Details Of Other Current Service Providers ( if Applicable )

( eg. Name, address, phone number / email / type of service / frequency of use, etc. )

6. Goals ( Participant's Short-term/Long-term Goals / NDIS Plan Goals ) *

Additional / Relavant Information

7. Referrer's Details( Person Making the Referral )

Firstname *

Surname

Phone number

Organisation

Position

Referrer Reason

I have to obtain consent from the participant to make this referral. *

8. Files Upload

( Please attach a copy of the current NDIS plan if possible & any other relevant documents )

Attachment 1

Attachment 2

9. CONSENT *

I consent to my information being provided to Australian Independence Health and Care for the purpose of referral, service delivery and inclusion in de-identified data reporting.

We are your PRESENT to empower your FUTURE

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AI Health and Care acknowledges the Traditional Custodians of the lands upon which we work and live throughout Australia and their continuing connection to land, sea and community. We pay our respects to the Elders past, present and future.

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