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? *

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

Plan Nominee Name *

Guardian Name *

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 Information

NDIS Number *

Current NDIS Plan Start Date *

Current NDIS Plan End Date *

From current NDIS Plan, please provide amount of funding
and quantity of hours remaining ( NOT amount/quantity allocated).

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 - Current Funding Available *

Psychology - Current Hours Available *

Other - Current Funding Available *

Other - Current Hours Available *

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

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 *

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.)

Today's Date *

Save and Complete Later

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