NDIS Online Referral Form | Accessible Allied Health Services

NDIS Online Referral

Please note that the following information/documents will be needed when completing this referral form:

• NDIS Number
• NDIS Plan
• Knowing if what services are NDIA Managed, Plan-Managed or Self-Managed (outlined in your NDIS Plan)
• Plan Manager contact and billing details if Plan-Managed
• Support Coordinator contact details
• Knowing if your plan is on Proda (old NDIA computer system) or Pace (new NDIA computer system). You would have been advised of this in your most recent Plan Review if you have moved to the new computer system.

LOCATION

Preferred service location *TelehealthPrivate ResidenceOther

Organisation *

Full Name *

Phone *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

Positive Behaviour Support Services *Positive behaviour support assessment and planPositive behaviour support, assessment, plan and ongoing intervention including stakeholder and family trainingRecommendation Letter to inform NDIS Plan Review

Occupational Therapy Services *Functional assessment and report outlining recommendationsSensory assessment and reportHome and living assessment (Supported Independent Living /Specialist Disability accommodation/Independent Living Options) and reportSkill building therapy by OT or Allied Health Assistant - minimumRecommendation Letter to inform NDIS Plan Review

Key Worker Early Childhood Support Services *Capacity building assessment, ongoing intervention to build functional independence and social participation and report

Physiotherapy Services *Physiotherapy assessment and report outlining recommendationsRecommendation Letter to inform NDIS Plan Review

Psychology Services *ADHD capacity assessment and report (14 years old+)Autism diagnostic assessment and report (16 years old+)Psychological diagnostic assessment and reportPsychological capacity building / psychological counsellingRecommendation Letter to inform NDIS Plan Review

Speech Pathology Services *Communication assessment and report outlining recommendationsCommunication assessment, report, and ongoing therapy by Speech Pathologist and/or Allied Health AssistantSpeech therapy and skill building by Speech Pathologist and/or Allied Health AssistantSwallowing assessment and mealtime management planSwallowing and communication assessment with mealtime management plan and communication recommendationsSwallowing and communication assessment with mealtime management plan and ongoing therapy by Speech Pathologist and/or Allied Health AssistantRecommendation Letter to inform NDIS Plan Review

Dietetic Services *Dietetics assessment and report outlining recommendationsDietetics assessment, ongoing therapy, and reportRecommendation Letter to inform NDIS Plan Review

Exercise Physiology Services *Recommendation Letter to inform NDIS Plan Review

PARTICIPANTS DETAILS

Select Pronoun *

Preferred Name *

First Name *

Last Name *

Date of Birth *

Gender *

Phone *

NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Email *

Select *

Residence Organisation *

Address *

Origin *First Nations PeopleCulturally and linguistically diverseN/A

Interpreter required *YesNo

Laguage and Dialects requirements *

Communication preferences or requirements *YesNo

Communication requirements *

Access requirements *YesNo

Access requirements *

ADVOCATE AND GUARDIAN INFORMATION

Organisation *

Full Name *

Phone *

Email *

Address *

PLAN NOMINEE

Do you have a plan nominee? *YesNo

Full Name *

Phone *

Email *

Address *

Select Contact Method *

FUNDING TYPE

Who will be responsible for paying for the services? *Self-managedAgency- managedPlan managedSelf funded (private patient)

Full Name *

Phone *

Email *

Address *

REFERRER INFORMATION

Please Select Referrer Type *

Organisation *

Full Name *

Phone *

Email *

Address *

DIAGNOSIS BACKGROUND

Please detail all diagnoses, disabilities, and/or health conditions *

DOCUMENTATION

Please provide a copy of the most recent NDIS plan and any previous allied health and medical reports, if available.