Online Referral

Online Referral Form

Date

Referrer Name

Referrer Organisation

Referrer Position

Referrers Email

Referrers Phone

Participant Name

Participant Date of Birth

Participant Identified Gender

Participant Address

Participant Phone Number

Does Participant have an NDIS plan?

Aboriginal or Torres Strait Islander?

Does the Participant require an interpreter?

Participant Disability

Please indicate how you would like us to follow-up on your inquiry (ie. NDIS support etc.)

Participant / Guardian Declaration

Client Address

I agree and consent to my information being provided to Deer Disability Services for the purposes of referral, service delivery and inclusion in de-identified data reporting.

Online Referral Form

PARTICIPANT DETAILS

First Name

Last Name

Gender

Date Of Birth

Address

Suburb

Postcode

State

Contact Number

Prefer Method of Communication

NDIS Number

NDIS Funding Type

If applicable, Plan Manager/Plan nominee details:

Name

Organisation

Contact Number

Plan start date

Plan end date

PERSONAL DETAILS

Aboriginal or Torres Strait Islander descent?

Living Situation

Do you have a current Behavioural Support Plan?

Primary Formal Diagnosis:

Secondary Formal Diagnosis:

Are there any legal issues that may affect our service? If applicable, please provide details

Other relevant information:

REPRESENTATIVE OR EMERGENCY CONTACT DETAILS

CONTACT 1:

CONTACT 2:

Name

Relationship to Client

Address

Contact Number

Advocacy Form Supplied?

COMMUNICATION

Type

Language Spoken

Is an Interpreter required?

PHYSICAL HEALTH

Medications (If applicable, please list)

I would like assistance with managing this by:

MENTAL HEALTH

Medications (If applicable, please list)

History of hospital admission

I would like assistance with managing this by:

DIETARY REQUIREMENTS

No dietary requirements

Vegetarian

Vegan

Dairy free

Gluten free

Allergies (If applicable, please list)

I do not like to eat: (please list)

My favorite food is:

PRACTICAL SUPPORT NEEDS

I require assistance with:

What Harmony Care services do you require?

Harmony Care can assist me by ….

YOUR PREFERENCES

Do you have specific preferences when matching our staff with you?:

Gender

Male Female Other

Age Group

Culture/Religion/Ethnicity

Languages spoken

Personality characteristics

Specific needs, skills or knowledge required?

Specific training that may be required to provide services and support to you?

Is there anything else you would like us to know about you that is important for how we provide our services to you?

What are your goals, expectations and desired outcomes when receiving our services?

What are your goals for the next 12 months?

CONSENT AND ACKNOWLEDGEMENT
By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan

Do you consent to participating in and use of:

Participating in audits of our business by the NDIS Commission and its auditors

Photos for Social Media

None of the above

Signed by the Client

Date

About Us

To be an organisation that empowers and supports
people from all areas of life, focusing on their
potential rather than their impairments.

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Harmony Care Support Services acknowledges the goals of the Convention on the Rights of Persons with Disabilities. We also acknowledge Australia’s traditional owners and their continued connection to land, sea, and community. We respect them and their cultures, as well as the elders of the past and present.

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Online Referral

Online Referral Form

Online Referral Form

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