Request For Service - Therapy
For Current NDIS Participants only

Participant Details

First Name *

Middle Name

Surname *

Preferred Name

Date of Birth *

Age

Gender *

Pronouns *

Please describe if "other" was chosen in "Gender"

Participant's Address *

Participant's Email Address *

Particpant's Mobile Telephone Number *

In Case of Emergency (Contact Name) *

Emergency Contact Address *

Emergency Contact Relationship to Client *

Emergency Contact Telephone Number/s *

Emergency Contact Email Address *

Do you/does the participant identify as part of the gender and sexually diverse (often known as LGBTQIA+) community? *

Are you/is the participant from an Aboriginal or Torres Strait Islander background? *

Are you/is the participant from a Culturally and/or Linguistically Diverse background? *

Language *

Interpreter Required *

Service Request Details

Who is making this Referral?

Referred by *

Referrer's Name (First Name & Surname) *

Relationship to Participant *

Referrer's Organisation *

Referrer Address

Referrer Contact Telephone number *

Referrer Email Address *

Service Request Consent

Who is providing consent to this request? *

Plan Nominee Name *

Guardian Name *

Please Note : A Support Coordinator is not considered an Authorised Representative.

Authorised Representative Name *

Authorised Representative Type *

Session and Contact Preferences

Please advise how you would like to attend sessions? *

Onsite in ClinicVia Telehealth

Preferred method of contact to organise an initial consult

Directly (client)EmailPhoneVia following parent/family/support

Parent/Family/Support Details

Other (please provide details)

Service Request and Funding Information

NDIS Number *

Current NDIS Plan Start Date *

Current NDIS Plan End Date *

It is important that remaining amount of funds for the service you are requesting
(not total) is recorded in this section. Please refrain from recording N/A (Not Applicable).

If you are unsure of how much funding remains,
you can obtain this information from your NDIS portal
or by calling the NDIS directly on telephone 1800 800 110 .

Failure to provide correct and current funding information in this section may result in
Guidestar being unable to accept your Request for Service.

Service Type / Service Category / Line item number *

Assessment, Recommendation, Therapy And/or Training – Psychology - 15_054_0128_1_3Assessment, Recommendation, Therapy And/or Training – Other - 15_056_0128_1_3

Psychology - Remaining Funding Available in current plan *

Psychology - Remaining Hours Available in current plan *

Other - Remaining Funding Available in current plan *

Other - Remaining Hours Available in current plan *

How will support be paid? (Please Choose One) *

If NDIA, please advise if plan is on PRODA or PACE *

PRODAPACE

Plan Management Provider Name *

Plan Manager Invoice to be emailed to *

Participant Nominee Name (if applicable) *

Self Managed/Participant nominee invoice to be emailed to *

I have checked the appropriate portal or called the NDIA. I confirm that the current funding and hours available recorded on this form are true and accurate. I understand that if information is incorrect, Guidestar may be unable to proceed with this referral until accurate funding information is provided. *

Service Agreement and Consent

Guidestar's Service Agreement and Consent Forms are sent via our client management system for electronic signing. If this request for service is accepted, please advise:

Person who will be signing Service Agreement and Consent *

Please provide email address to send Service Agreement and Consent to *

Please Note : A Support Coordinator is not considered an Authorised Representative.

Please provide Authorised Representative's full name *

Please provide Authorised Representative's legal relationship to client *

Please provide Authorised Representative's email address to send Service Agreement and Consent to *

Purpose of Support / NDIS Goals

Summary of reason for referral and expected outcomes *

Supporting Participant Information

Relevant Diagnoses *

Physical Support Needs (ie., equipment, etc.) *

Communication (i.e., sign, use of visuals, etc.) *

Recent changes or significant events (i.e illness, bereavement, transitions etc.) *

Experience (or witness) of personal trauma and/or abuse *

Other information: Is there anything else you would like the therapist to know? (i.e., programs, employment, respite, etc.)

NDIS Plan

Please upload a copy participant's CURRENT NDIS plan here *

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Today's Date *

Save and Complete Later

Request For Service - Therapy *For Current NDIS Participants only*