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Services
Occupational Therapy
Speech Pathology
Physiotherapy
Behavioural Support Services
Psychological Support Services
Support Coordination
Information for Participants
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Referral Form
(02) 9588 9829
NDIS Referral Form
Fill out the form below to refer a participant for NDIS services at PRS Support.
Referrer Details
Referrer Name
Organisation
Phone
Email
Role
Participant Details
Participant Name
DOB
Phone
Email
Gender
Male
Female
Non-Binary
Preferred pronoun:
Preferred method of contact
Phone
SMS
Email
Support Coordinator
Address
Suburb
Post Code
Interpreter required
Yes
Language:
Contact person for making the appointment (name & number)
Current medical condition/disability
Is Participant in: My NDIS Provider Portal (PACE):
No
Yes
If yes, please provide copy of NDIS plan, alternatively we will need a screen shot of: Plan dates, Funding category & Goals
NDIS Plan Details
NDIS Number
Plan Start and End date:
Who manages the plan?
Agency Managed
Self-Managed
Plan Managed
Plan Manager Details and email to send invoice
Funding Category
Improved Daily Living
Improved Relationships
Other Category
Improved Relationships (Please provide a breakdown below of Specialist Behaviour Intervention Support and Behaviour Management)
Funding available for PRS:
Participant Representative Details
Name
Relationship to Participant
Phone
Email
Reason For Referral
Occupational Therapy
Therapy Services (ongoing therapy)
Weekly
Fortnightly
Monthly
Functional Assessment and Report
Standard (12hrs)
Comprehensive (15hrs)
Assistive Technology Home Modifications
SIL Assessment
SIL + SDA Assessment
Sensory Assessment
Standard (15hrs)
Comprehensive (20hrs)
Behaviour Support
Therapy services (ongoing therapy)
Weekly / Fortnightly / Monthly
Behaviour Support Plan
Recommendations Letter
Psychological Support
Therapy Services (ongoing therapy)
Weekly / Fortnightly / Monthly
Psychological Assessment
Recommendations Letter
Cognitive Assessment
Exercise Physiology
Therapy Services (ongoing therapy)
Weekly
Fortnightly
Monthly
Assessment
Exercise intervention planning
Speech Pathology
Therapy Services (ongoing therapy)
Weekly
Fortnightly
Monthly
Swallowing Assessment
Mealtime Management Plan
Speech Assessment
Support Coordination
Yes
Additional Information
Goals of NDIS Plan related to service request
SCREENING RISK ASSESSMENT
Type of Residence
House
Unit
Office
Aged Care Facility/Group home
Detention Centre
Hospital
Other
Specific instructions to access the residence
OCCUPANT/S
Does the participant or other people in the home have a history of actual or threatened violence or aggressive behaviour?
No
Yes
Does the participant have a positive behaviour support plan in place?
No
Yes
Is it likely that any people within the home will be smoking or drinking alcohol during our visit?
No
Yes
Is there known substance abuse amongst people who may be present?
No
Yes
Are you aware of any occupant having an infectious disease?
No
Yes
Are there any pets at the premises?
No
Yes
HAZARDS
Are there any known weapons in the house?
No
Yes
Is there difficulty with mobile phone reception?
No
Yes
Are there any potential hazards that you are aware of that would make access to this property difficult?
No
Yes
OTHER SAFETY CONCERNS
Are there any other safety concerns we should be aware of?
No
Yes
OUTCOME
Risks identified?
No
Yes
Submit
