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1300 237 634
info@australiadisabilityservices.com.au
Referral
Allied Health

    Participant Details

    Client Full Name *

    NDIS Number *

    Plan Start Date *

    Plan End Date *

    Email Address *

    Participant Phone *

    Date of Birth

    Please Select Age Range

    Participant Address

    Gender

    Diagnosis & Service

    Diagnosis *

    Main Reason For Referral

    What services do you require? *

    Is the participant living in a residential aged-care facility? *

    Is the Participant *

    Is an interpreter required? *

    If yes, which language or dialect *

    Relationship to Participant

    Does the participant have a nominee, or are they their own decision maker?

    Next of Kin/ Emergency Contact

    Name

    Phone Number

    Relationship with Participant

    Email

    Referrer Details

    Name

    Phone Number

    Relationship with Participant

    Email

    Plan Details

    How is the participant's plan managed

    Plan Manager Details

    Name

    Email

    What Funding Allocation do you have in your NDIS plan?

    Does the participant have a history of aggressive behaviours towards others?

    Does the participant have a previous behavioural support plan?

    Consent

    Australia Disability Services (ADS) is committed to providing high-quality support services. To assess eligibility and develop appropriate support plans, we need to collect personal information about the participant. Without this information, we may be unable to process the referral or deliver the necessary services.

    By submitting this referral form, you acknowledge and consent to the following:

    1. Collection of Information: ADS will collect and store the participant’s personal details to assess their needs and provide appropriate support services.

    2. Use of Information: The collected information will be used for service planning, coordination, and assessment. It may be shared with relevant professionals within ADS involved in the participant’s care.

    3. Disclosure to Third Parties: Information may be shared with healthcare providers, educators, or other relevant professionals where necessary to facilitate the participant’s support plan. Any disclosure will comply with privacy laws.

    4. Privacy and Access: ADS is committed to protecting your privacy. Our Privacy Policy, available on this website, outlines how personal information is collected, stored, and managed. You have the right to access or request corrections to your personal information at any time. By submitting this form, you consent to the collection and use of your information in accordance with our Privacy Policy.

    E.g., GP/Specialist

    Does not have consent to talk to anyone? Please specify.

    Consent to Record

    I consent to Australia Disability Services making audio and/or video recordings of the participant for:

    • Individual therapy planning and assessment

    • Supporting evidence for disability-related funding applications

    All recordings will be securely stored and used only for professional purposes.

    Consent to Physical Guidance

    I acknowledge that, where necessary, physical guidance may be provided during therapy or support sessions. This may include:

    • Hand-over-hand assistance

    • Guided positioning for safety and comfort

    All physical guidance will be conducted with the utmost care, respecting the participant’s dignity and comfort.

    Declaration of Consent

    By submitting this referral form, I confirm that:
    ✔ I have provided accurate and complete information.
    ✔ I understand why this information is being collected and how it will be used.
    ✔ I consent to the collection, use, and disclosure of this information as outlined above.
    ✔ I understand that ADS may seek additional consent for any other use of this information.

    Full Name *

    Select a Date *