What type of referral is this? What type of referral is this? NDIS Aged Care Other

First Name

Last Name

Phone Number

Email

My relationship with the person needing support

Organisation Name (if applicable)

I have consent from the client to make this referral I have consent from the client to make this referral Yes No

If consent is not given by the client, consent is provided by

Client First Name

Client Last Name

Date of Birth (DD/MM/YYYY)

Gender GenderMaleFemaleNon Specific

NDIS Number

My Aged Care / Referral Code

Can the client be contacted directly? Can the client be contacted directly? Yes No

Client Phone Number

Client Email

Client Address

Suburb

State StateNSWQLDVICACTSAWATASNT

Postcode

Interpreter Required? Interpreter Required? Yes No

Preferred Language

Does the client identify as Aboriginal and/or Torres Strait Islander? Does the client identify as Aboriginal and/or Torres Strait Islander? Yes No Prefer not to say

Primary Disability

Diagnosis & Living Arrangements (group home, supported accommodation, independent, family)

High Risk Support? High Risk Support? Yes No

If there is risk, please provide details here

Plan Start Date (DD/MM/YYYY)

Plan End Date (DD/MM/YYYY)

How is the plan managed? How is the plan managed?NDIA managedSelf managedPlan managedOther

Plan Manager details (name, contact, email)

Support Required Support Required Accommodation Services (Respite, STA, SIL, SDA, MTA) Assistance with Daily Living Activities Personal Care Shopping Assistance Skin Integrity Management Social Support / Companionship Support Coordination Support for Independence and Skill Building 24/7 Care Support

Is a Home Care Package assigned? Is a Home Care Package assigned? Yes No

What level Home Care Package is assigned? What level Home Care Package is assigned?Level 1Level 2Level 3Level 4

Does the client have a current service provider for their Home Care Package? Does the client have a current service provider for their Home Care Package? Yes No

Name of the current provider organisation

GP Name

GP Phone Number

GP Address

Summary of medical history / details relevant to this referral

Support Required Support Required Domestic Assistance Transport Personal Care Shopping Social Support - Individual Social Support - Group Physiotherapy Occupational Therapy Respite Meal Preparation Nursing Services

Does the client have a carer / support person / guardian? Does the client have a carer / support person / guardian? No Yes - the referrer Yes - specified below

Carer / Guardian Name

Carer / Guardian Phone

Carer / Guardian Email

Carer / Guardian relationship to client

Who is the best communication contact? Who is the best communication contact? The referrer The client The carer specified above None - another person specified below

Contact Name

Contact Phone

Contact Email

Relationship to client

Additional information (days & hours per week required, urgency, special requirements, etc.)

Link to supporting documents (Google Drive / Dropbox / OneDrive share link)

I have read the privacy collection notice and consent to Quality Care Plus contacting me regarding the information in this referral I have read the privacy collection notice and consent to Quality Care Plus contacting me regarding the information in this referral Yes No