My Access Care Australia

e. [email protected] | p. 1800 634 762 or (03) 7047 6647

Participant Referral Form

This form will be used to gather complete information when we meet in person.

Once the form is submitted, you can expect to hear from us within 2 working days.

If you would like to speak with us sooner, please call us on 1800 634 762 or (03) 7047 6647, or email us at [email protected]

Date of Referral*

Personal Information of Participant

First Name*

Last Name*

Preferred Name

Date of Birth*

Phone Number

Address*

Suburb*

State*

Postcode*

Living Arrangements*

AIndependently

BSupported Residential Service (SRS)

CSupported Independent Living (SIL)

DSpecialist Disability Accommodation (SDA)

EShared Accommodation

FRooming / Boarding House

GWith Parents

HWith Friends

IWith Relatives

JFoster Care

Gender*

AMale

BNon-Binary / Gender-Fluid

CFemale

DOther

Identified As*

AAboriginal

BNeither

CTorres Strait Islander

DPrefer Not To Disclose

EBoth Aboriginal and Torres Strait Islander

Primary Diagnosis (if known)*

(i.e. Autism Spectrum Disorder, Downs Syndrome, etc.)

Support Services Required*

ASupport Coordination

BHousehold Tasks (incl. Cleaning, Gardening, Laundry, Meal Prep., etc.)

CAssistance with Self-Care Activities

DAssistance with Social, Economic, and Community Participation

ETransport & Travel

Specific Details and Frequency of EACH Support Service Required (except Support Coordination)*

Please Provide the Specific Details and Frequency of EACH Support Service Required (i.e. Cleaning, Showering, Community Engagement, etc.)

My Ideal Support Worker (except Support Coordination)*

e.g. When I access supports, I feel more comfortable working with support workers who: (specify preferred gender, age range, social background etc.). Identify preferences, clearly identify exclusions: Person will not work with 'X' but will work with 'Y'. Articulate to the participant that we are not able to discriminate, but we can work with preferences aligned with their support goals.

Required Start Date for Supports*

NDIS Information

Participant's NDIS Number*

Current Plan Start Date*

Current Plan End Date*

How is the Participant's NDIS Plan Managed?*

AUnsure

BNDIA-Managed

CSelf-Managed

DPlan-Managed

Please Provide Name of Plan Manager, Contact Phone Number, Address and Email Below*

Does the Participant Have a Current Support Coordinator?*

AUnsure

BNo

CYes

Please Provide Name of Support Coordinator, Contact Phone Number and Email Below*

Please Upload a Copy of the Participant's Current NDIS Plan (if available)

Whilst not required, providing the NDIS plan allows us to understand the participant's goals and support needs, enabling us to tailor our services and ensure effective support delivery. This also helps us to align our services with the participant's individual needs and preferences, promoting choice and control.

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Participant's Representative

Does the Participant have a representative who is authorised to act on their behalf?*

If Yes, please complete the Participant Representative Details section that will display below after selecting "Yes"

AYes

BNo

If the Participant has a legally appointed or authorised representative (such as a nominee, guardian, administrator, parent, or informal decision-maker), please complete the details below.

The representative listed in this section will be recorded as the primary contact person for the Participant and will be responsible for:

* Providing instructions on behalf of the Participant

* Receiving service-related communications

* Approving supports and scheduling

* Signing all service agreements, consent forms, and related documentation

My Access Care Australia will rely on the authority of the representative named below unless notified in writing of any change.

Full Legal Name of Representative / Nominee*

Relationship to Participant*

AParent

BGuardian

CNominee

DAdministrator

ESupport Person

FOther

Type of Authority*

ANDIS Nominee

BGuardianship Order

CAdministration Order

DInformal Representative

EOther

Organisation (if applicable)

Postal Address*

Email Address*

Primary Contact Phone Number*

Alternate Contact Phone Number

Authority and Signing Declaration

I confirm that I am authorised to act on behalf of the Participant named in this referral and that I will be the primary contact person for all communications relating to their supports with My Access Care Australia.

I understand that I will be responsible for reviewing and signing all service agreements, consent forms, schedules of support, and related documentation on the Participant’s behalf unless otherwise advised in writing.

Representative's Signature*

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Representative's Name*

Date*

Information of the Person Completing This Form

Organisation

First Name*

Last Name*

Relationship to Participant*

Phone Number*

Email*

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