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NDIS Participant Referral Form

Thank you for your referral. To help us support your client in the best way possible, please complete the form below with as much detail as you can. If you have a copy of the participant’s NDIS plan, feel free to upload it — it really helps us get a clearer picture and provide the right support from the start.

Referrer Details

Name(Required)

Email(Required)

Phone(Required)

Company & Address (if relevant)

Role(Required)

Participant Details

Name(Required)

Date of Birth (DOB)(Required)

Address

Phone & Email

NDIS Compensable Disability

Referral Reason

Other reason for referral

NDIS Plan Details

NDIS Participant Number

NDIS Plan Start Date

NDIS Plan End Date

Payment (NDIS standard hourly rate $193.99)

How many hours do you require?(approx)

Who is responsible for payment?

Plan Manager

Self

Email for billing

OT Home Visit Risk Assessment (Please complete accurately to ensure the safety of our therapist entering the home of participants.)

Living situation (eg. alone, family, supported accommodation)

Does the participant live in an isolated area?

Yes

Are pets present? (Pets to be restrained at time of assessment)

Yes

Does anyone at the property have an infectious disease?

Yes

Are there firearms in the home?

Yes

Is there mobile phone coverage?

Yes

Does anyone at the property have a history of being aggressive/ violent?

Yes

Are there any other factors relating to the safety of our therapists entering the property?

Yes

Does anyone at the property have a history of alcohol or illicit drug dependence?

Yes

Any other information you think we should know?

Occupational Therapist

Hayley Owoeye

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