NDIS Paediatric Referral Form Fill out our easy online referral form below! We will be in touch as soon as possible. PARTICIPANT INFORMATION Full name: * First Name Last Name Preferred name: DOB: * MM DD YYYY Gender: Female Male Non-Binary Other Pronouns: she/her/hers he/him/his they/them/theirs other Address: Does the participant identify as Aboriginal or Torres Strait Islander? Yes No Prefer not to say Is an interpreter required? Yes No If yes, please provide details: Current childcare/kindergarten/school: Year level (if known): Care Arrangements: N/A Informal shared care Court ordered shared care Court order in place DCP Foster Care REFERRAL DETAILS Service required: Occupational Therapy Speech Therapy Reason for referral: Preferred location for appointments: Clinic Childcare/Kindy/School Home A combination of the above Unsure at this stage Preferred frequency of therapy: Weekly Fortnightly Monthly Assessment only Unsure at this stage DISABILITY Diagnosis: * Other Medical History/Allergies: Are there any behaviours of concern? PRIMARY CONTACT DETAILS- CAREGIVER 1 Full Name: * First Name Last Name Phone: (###) ### #### Address: Same address as participant Other If other address, please provide below: Email: Relationship to Participant: * SECONDARY CONTACT- CAREGIVER 2 Full Name: First Name Last Name Phone: (###) ### #### Address: Same address as participant Other If other address, please provide below: Email: Relationship to Participant: NDIS DETAILS NDIS number: Plan End Date: Fund management: Plan Self Agency If plan managed, please provide the name of your Plan Manager: NDIS nominee/Signatory for the service agreement * Caregiver 1 Caregiver 2 Other If other, please provide name, relationship to participant and contact details: HOME VISIT RISK ASSESSMENT If services are to be provided in the participants home, please answer the following questions: Is the residence difficult to find? Yes No If so, please provide information regarding how to access the residence: If there are any aggressive or disruptive pets in the house, can they be placed in a different room during the therapists visit? Yes No If someone smokes or uses illicit substances inside the house are they able to refrain during the therapists visit? Yes No Is there presence of violence, conflict of aggression from anyone in the residence? Yes No If so, please describe how the risk will be mitigated during the therapists visit: REFERRER DETAILS Who is making the referral? * Caregiver 1 Caregiver 2 Support Coordinator Other If other, please describe your relationship to the participant and provide name and contact details: Who is the best person to contact to organise an appointment? * Caregiver 1 Caregiver 2 Support Coordinator Other If other, please provide name, role and contact details: SUPPORT COORDINATOR DETAILS (if applicable) Name First Name Last Name Email Phone (###) ### #### Organisation (###) ### #### OTHER Is there any other information you would like to provide? If you are new to Thrive Health Therapies, how did you hear about us? Internet Search/Website Social Media Word of Mouth Flyer/Brochure Events Other Thank you!
