My Access Care Australia

e. [email protected] | p. (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 (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.

Choose a file or drag and drop here

Uploading...

Information of the Person Completing This Form

Organisation

First Name*

Last Name*

Relationship to Participant*

Phone Number*

Email*

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