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Referral Form
NDIS Referral
Step
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10
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This form is for NDIS referrals. For all other enquiries please visit our contact page. Please note that at this time we are unable to provide services for children. Referrals for adolescents are considered on a case by case basis.
Details of person completing this form
Are you completing this form on behalf of someone else?
(Required)
Yes
No
Your name (person filling out this form)
(Required)
First name
Last name
Name of referring organisation (if applicable)
Email address of person completing this form
(Required)
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
Your relationship to the NDIS Client
(Required)
Support Coordinator
Case Manager
Local Area Coordinator
Family Member
Carer
Other
Check this box to indicate that consent is given to share information about the NDIS client with us:
(Required)
Yes, I am authorised to submit this referral and share information about this NDIS client.
Please continue by clicking the "Next" button.
NDIS client details
NDIS Participant’s name
(Required)
First name
Middle name
Last name
Preferred name
(Required)
Date of birth
(Required)
DD slash MM slash YYYY
Email address
(Required)
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
My pronouns are
He, Him, His
She, Her, Hers
They, Them, Theirs
Let me type
Pronouns (let me type)
Gender
(Required)
Female
Male
Non-binary
Transgender
Intersex
I prefer not to say
Let me type
Choose as many as you like.
Gender (let me type)
(Required)
Address
(Required)
Street Address
Suburb
State
Post Code
NDIS client details
Is the NDIS participant of Aboriginal and/or Torres Strait Islander origin?
(Required)
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Preferred language
Afrikanns
Albanian
Arabic
Armenian
Basque
Bengali
Bulgarian
Catalan
Cambodian
Chinese (Mandarin)
Croation
Czech
Danish
Dutch
English
Estonian
Fiji
Finnish
French
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Irish
Italian
Japanese
Javanese
Korean
Latin
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Nepali
Norwegian
Persian
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Samoan
Serbian
Slovak
Slovenian
Spanish
Swahili
Swedish
Tamil
Tatar
Telugu
Thai
Tibetan
Tonga
Turkish
Ukranian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Is a translator required?
Yes
No
Please select the NDIS Participant’s living arrangement
(Required)
Living alone
Living with family/partner
Supported accommodation
Other
Does the participant have a legal guardian?
(Required)
Yes
No
Guardian's name
(Required)
First name
Last name
Email address
(Required)
Copies of all correspondence will be sent to this email address.
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
NDIS client details
NDIS Plan Number
(Required)
NDIS start date
(Required)
DD slash MM slash YYYY
NDIS end date
(Required)
DD slash MM slash YYYY
Primary disability
Please list disabilities
(Required)
Reason for referral
Select reason for referral
(Required)
Assistive technology (equipment)
Functional assessment
Home modification
Housing assessment (SDA/SIL/ILO)
OT assessment with a sensory focus
OT Driving Assessments
OT therapy services
Pre-planning or plan review assessment
Psychosocial assessment or services
Therapy Assistant
Other
OT Driving Assessment
(Required)
I am located in South Australia and I acknowledge that I’ve selected OT Driving Assessment as the referral type and that I am joining the waitlist for the next available appointment. I understand that ActivOT will contact me when an appointment for this service becomes available.
I am located in Queensland and understand I will be contacted by ActivOT to have an appointment time allocated for an OT Driving Assessment.
Other
(Required)
What would you like to achieve from this referral?
(Required)
Safety & environment
Has your organisation completed a home risk assessment previously?
(Required)
Yes
No
Unsure
If yes, please provide details
(Required)
Has the home been attended in person in order to identify any risks?
(Required)
Yes
No
Unsure
If yes, please provide details of risks
(Required)
Are there any areas of concern? Example history of violence / sexual risk / self harm or aggression?
(Required)
Yes
No
Unsure
If yes, please provide details
(Required)
Are there any pets/animals on the premises?
(Required)
Yes
No
Unsure
If yes, please provide details of pets/animals
(Required)
Are you aware of any drug/alcohol abuse?
(Required)
Yes
No
Unsure
If yes, please provide details of drug/alcohol abuse
(Required)
Are there any weapons stored on the premises?
(Required)
Yes
No
Unsure
If yes, please provide details of weapons
(Required)
Are there any environmental concerns (for example hoarding/limited access to property/pest or rodent infestation?)
(Required)
Yes
No
Unsure
If yes, please provide details of environmental concerns
(Required)
Are there any other safety factors we should be aware of when visiting this client at home on their own?
(Required)
Yes
No
Unsure
If yes, please describe
(Required)
Are you fully vaccinated against COVID-19?
(Required)
Yes
No
Unsure
Payment of accounts/invoices
Who is responsible for paying the account/invoice?
(Required)
NDIA / Agency Managed
Plan managed (organisation name provided)
Self managed
Name of the person responsible for the account
(Required)
First name
Last name
Organisation (if applicable)
Email address
(Required)
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
Communication preferences
Who is the primary NDIS contact for signing service agreements?
(Required)
NDIS participant
Legal guardian
Plan Nominee
Other
Primary contact name
(Required)
First name
Last name
Email address
(Required)
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
Please explain why this person is responsible for signing the service agreement
(Required)
Who should receive appointment notifications?
(Required)
The person filling out this form
NDIS participant
Legal guardian
Plan nominee
Other
Name of other contact
(Required)
First name
Last name
Email address
(Required)
Phone number
(Required)
Please enter 10 numbers (either your mobile or landline including area code).
Relationship to NDIS participant
(Required)
Family member
Support Coordinator
Carer
Other
Additional information
Please provide any additional information
Upload supporting documentation
Drop files here or
Select files
Max. file size: 128 MB.
Please upload any supporting documentation, including relevant doctor’s reports, NDIS goals, and COVID-19 Digital Certificate.
ActivOT Practice
Please select your preferred ActivOT Practice
No preferred practice, please advise me
Queensland
South Australia
New South Wales
Victoria
Western Australia
Queensland
Belinda Wallace, Maroochydore
Chloe Ditchfield, Narangba
Emile Dabrowski (TA), Clear Island Waters
Gareth Wilson (TA), Mermaid Waters
Katie Yeates, South Burnett
Keeva Simon, Moreton Bay
Krishna Nahow, Nundah
Lizzy England, Northside
Nora English, Sunshine Coast
Sarah-Beth Schiappadori, Outer North Brisbane
Simon Dabrowski, Gold Coast
Matika Handley, Upper Coomera
Suzy Heeks, Nambour
Vidhi Mittal, Pimpama
South Australia
Alethea Sifis, Adelaide
Amy Wigmore, Blackwood
Andy Shia (TA), Croydon Park
Anna Westlake, Prospect
Ashleigh Bateson, Woodville
Brian Lai, Marion
Cathy Aldridge (TA), Alberton
Clare Williams, Brompton
Courts Karoubas, Burnside
Danielle Spencer, Highbury
Emily Tsoutouras, Torrens Park
Emma Hill, Croydon
Fiona Hutcheson, Ethelton
Georgia Hondrovasilopoulos, Fitzroy
Georgie Simon,West Lakes
Gosia Speed, Physiotherapy, Hindmarsh
Hayley Vince, Summertown
Hilda Ho, Physiotherapy, Modbury
Jade Norsworthy, Kensington
Jane Brennan, Copper Coast
Jessica Rainbird, Belair
Julie Banks (TA), Collinswood
Julie Kenyon, Stirling
Katie de Zeeuw, Semaphore
Kerin Smith, Dernancourt
Maggie Gibson, Onkaparinga
Marianne Tan, East Adelaide
Mark Allcock, Henley Beach
Natasha Chajka, Northfield
Nerida Polkinghorne, Bowden
Rosetta Cafuta, Kidman Park
Sandra Afnan, Bridgewater
Sarah Guthrie, Gumeracha
Sarah Posaner, Adelaide Hills
Siobhan Tothill, Mitcham
Steve McGregor (TA), St Peters
Suzy McCallum, Norwood
Talia Dent, Pasadena
Taryn Morrison, Golden Grove
Tessa Shalay, Kangaroo Island and Fleurieu Peninsula
Tony De Minico (TA), Thorngate
Yang Lu, Myrtle Bank
New South Wales
Sinini Mlilo, Campbelltown
Michelle Julianes, Rouse Hill
Victoria
Pamela Borg, Melbourne and surrounds
Tarryn Brady, Ouyen
Western Australia
Theresa Foppoli, Wangara
Joanne Skelton, Joondalup
Complete your referral form
How did you hear about us?
(Required)
Social media (Facebook, Instagram, LinkedIn)
Advertisement (Facebook, Instagram, LinkedIn, Google)
Expo
Referral (name and job title required)
Search engine (Google, Bing, etc)
Other
To complete your referral form click the "Submit" button below. When your information has been sent successfully you will receive a confirmation email. Following receipt of this referral form we will be in contact with you to discuss your needs and to arrange a service agreement.
Name
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