Referral for NDIS Services
Please ensure all sections of this referral are completed in order for it to be processed in a timely manner.
Email completed form to reception@alliancerehab.com.au or fax through to (07) 4771 6971. 	

Personal Details
Family name:			Phone (Home):		
Given name:			Phone (Work):		
Date of birth:  			Email Address: 		
Address:			
Sex:	  Male        Female

How would you like us to contact you?
  Phone        Email          Text         Via Mail/Post:				
  or another person contacted on my behalf:				

Who is your:
  Support Coordinator: 
Name: 			Phone (Work):		
  Local Area Coordinator:
Name: 			Phone (Work):		
  Support Worker
Name: 			Phone (Work):		
  Contact Person for Appointments and Scheduling 
Name: 			Phone (Work):		

About Me: 

Primary disability & health history: 

My NDIS Goals: 

Reason for referral: 

Services you would like to access at Alliance Rehabilitation:
  Physiotherapy	  Occupational Therapy 
  Social Work		  Speech Pathology
  Dietitian		  Exercise Physiology 
  Psychology		  Hydrotherapy
  TyroMotion (Robotic & Computer aided)	  Groups
  Driving Assessment 	  Home Modifications
  Assistive Technology	  Functional Needs Assessment
  Support Coordination	  Other Services:		

NDIS Plan Details	
Do you have an approved NDIS Plan?:      Yes     No
NDIS Number:			Plan start & end dates: 		
  I can sign Service Agreements myself               I have a Plan Nominee who signs my service agreements
What categories of funding do you have in your NDIS Plan?:
  Improved Daily Living      Health & Well Being     Improved Relationships     Support Coordination
How is your NDIS Plan Managed (how are services paid?):
  National Disability Insurance Agency(NDIA)/Portal	  Self-Managed 
  Plan Management Organisation pays my bills: 
Name of Org:			Email Address: 		

Do you have a legal guardian via the Office of Public Guardian (OPG)?    
  Yes       No

Has there been a recent hospital admission?
  Yes       No    (If Yes, provide Date/Reason/Length of stay & Medical Clearance from your G.P. if appropriate.)
		
Have referrals been sent to services other than Alliance Rehabilitation? (Please list)
				
Are there other services currently involved? 

Consent for referral
  Yes - this referral has been discussed with the participant and/or their guardian, and they understand and agree with the referral being made.

Referrer Details: 
Referrer Name:			Phone (Work):		
Discipline:			Fax (Work):		
Address:			Email: 		

Signature:			Date