Appointment
Referral Form

Referral Form

Please ensure you have the following information and documents available before completing this referral form:

 

  • Your NDIS participant number

  • A copy of your current NDIS Plan

  • Details of how each service is managed (NDIA-managed, plan-managed, or self-managed), as outlined in your NDIS Plan

  • Plan manager contact and billing details, if your plan is plan-managed

  • Support coordinator contact information, if applicable

  • Confirmation of whether your plan is on the PRODA (previous NDIA system) or PACE (current NDIA system). This information is provided during your most recent plan review if you have transitioned to the new system

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Location

Preferred service location

Participant Details

Origin
Interpreter required
Communication preferences or requirements
Access requirements

Advocate and Guardian Information

Does the participant have

Referrer Information

Diagnosis and Background

Documentation

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Risks and Safety

Are there any legal or court orders currently in place, including bail, parole, family law, or domestic violence orders?
Has the participant ever displayed physical aggression toward allied health professionals, medical practitioners, or support staff?
Has the participant ever been detained in a prison, juvenile detention facility, or forensic hospital due to a violent or sexual offence?
Is the participant currently experiencing issues related to alcohol or drug misuse?
Are there any known safety risks associated with visiting the participant in their home?
Is there any additional information we should be aware of about the participant, such as triggers for distress or aggression, or particular topics, activities, or items that may cause discomfort? Are there any specific likes or dislikes?

Initial Assessment

Appointment preferences
I agree that a full service fee will be charged if changes or cancellations are not made at least two business days before the appointment. No cancellation fee will apply if the appointment is cancelled or rescheduled with sufficient notice.

Service Agreement

Who will sign the service agreement

Payment Method

Who does ORS invoice? (please select all that apply)

Travel disclaimer

I understand and agree that travel costs, including up to 30 minutes of travel time each way and per-kilometre mileage charges, will be applied in line with the current NDIS Price Guide.

Further Information

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Consent

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