NDIS Referral Form CLIENT DETAILS Name * First Name Last Name Preferred Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth MM DD YYYY Disability/Diagnosis * CLIENT CONTACT DETAILS Client Phone (###) ### #### Client Email **This is required if the client is signing the Service Agreement ADDITIONAL CONTACT DETAILS Who else should be recorded as a contact on the client file? * No Additional Contacts Next of Kin (NOK) NDIS Nominee (If Different to NOK) Support Coordinator House Manager Other COMMUNICATION PREFERENCES Please verify that the details of these individuals have been included as "Additional Contacts" above Who is the primary contact for scheduling appointments * Client Next of Kin (NOK) NDIS Nominee Support Coordinator Other Who should receive copies of the Service Agreement for signing? *Service agreements are sent via email, ensure email address included in contact details * Client Next of Kin (NOK) NDIS Nominee Support Coordinatorr Other NDIS PARTICIPANT DETAILS NDIA Number (9-digit number found on the participant’s NDIS plan) * NDIS FUNDING DETAILS NDIS Plan Start Date * MM DD YYYY NDIS Plan End Date * MM DD YYYY Has NDIS Funding been received on or after 19/05/2025 and fall under NDIS PERIOD FUNDING Yes (Please fill in period funding dates/amounts below) No HOW IS THE PARTICIPANTS NDIS FUNDS MANAGED? * Agency Managed Self Managed Plan Manager OT SERVICES REQUIRED (REASON FOR REFERRAL) * Functional Capacity Assessment Assistive Technology (Equipment Assessment) SIL Assessment SDA Assessment Home modification Manual Handling Assessment Daily Living Skills/Capacity Building Intervention Mental Health Intervention Other/Not Sure NDIS GOALS Further information that will assist us in allocating this referral Are there any known safety risks for the Occupational Therapist when working with this client or when they are in their home environment. Yes No Has this referral already been discussed with the Referral Intake Officer? * Yes No DETAILS OF PERSON COMPLETING FORM Relationship to Client (Person Completing Form) Family Member Support Coordinator Other Organisation Name Name * First Name Last Name Position/Relationship * Phone * (###) ### #### Email * CONSENT TO SUBMIT REFERRAL * I agree that I have the client or the Nominee's consent to share their personal information with Independent OT for the purpose of Occupational Therapy Assessment and/or services. Thank you for submitting your referral. One of our occupational therapists will be in touch shortly.
