taraharding@nqsupportcoordination.com
+61 455 490 069
Referral Form
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Referral Form

All sections of the referral form must be completed.

This referral is for:

1. Participant Details

Gender
Indigenous / Ethnicity
NDIS Plan Copy Attached
Behaviour Support Plan Attached
Living Arrangements
Primary Contact Type

2. Referral Details

Referrer Role

3. Diagnosis / Presenting Issues

Please specify disability, medical, mental health and other presenting issues.
Please specify any known supports or services currently in place.

4. Reason for Referral

5. Home Visit Screening Questions

For the safety of our staff, it is mandatory this section is completed in full.
Is anyone at the client's property known to be aggressive or violent?
Are you aware of there being firearms at the property? If yes, are they locked away securely?
Are you aware of any occupant having an infectious disease (e.g. chicken pox, shingles or gastro)?
Are you aware of any risks related to pets or animals on the premises?
Does anyone in the house smoke? If yes, are they happy to refrain while the coordinator visits?
Is the house easy to find and is parking available?
Are there any other factors we should know about when visiting this client at home alone?
Please provide details for any Yes response, and parking directions if required.

6. Service Requested and Cost of Service

Support Coordination is charged in 15-minute blocks. Work outside weekday daytime is charged at applicable rates. Charges apply to visits, phone calls, emails and research and may change in line with NDIS price guides.

Session charges include administration and follow-up. Home, school and community visits may incur travel time and per-kilometre charges under the current NDIS Pricing Arrangements and Price Limits.

Service(s) Requested
07_002_0106_8_3; $100.14 per unit
07_105_0106_6_3; $200.39 per unit
07_002_0106_8_3; $100.14 per unit
07_002_0106_8_3; $140.19 per unit
07_004_0132_8_3; $190.54 per unit
07_004_0132_8_3; $266.75 per unit

7. Inclusive Service Needs

Please tell us about any culture, religion, values, beliefs, communication, accessibility, gender or sexual-expression considerations we can accommodate.

8. Payment of Account

Who is responsible for paying the account?

9. Additional Information