Participant details *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Carer/Guardian Details 1

First Name

Last Name

Parent/Carer/Guardian Details 2

First Name

Last Name

If you are NOT the parent/carer/guardian completing this referral (for eg Coordinator of Supports or Professional Referrer, please complete your details below:

First Name

Last Name

Education

Do you/the child attend pre-school/childcare/school?

Yes

No

We have HICAPS facilities for Fee For Service, Private Health Insurance and Medicare GP care plans. Do you have a Medicare GP Care Plan?

(If yes please upload a copy of your care plan).

Yes

No

Do you have a diagnosis?

Yes

No

Plan start date

MM

DD

YYYY

Plan review date

MM

DD

YYYY

How is your NDIS plan managed?

Self managed

Agency managed

Plan managed

If your NDIS is plan managed, who is it managed by?

First Name

Last Name

We offer a wide range of services of therapies and supports to suit your needs. Please select from the list below. If you are unsure or unfamiliar our experienced intake team will guide you through the supports and therapies best suited to your needs.

Therapy Services

Specialist Teacher

Psychology

Physiotherapy

Allied Health Assistance

Speech Pathology

Occupational Therapy

Dietetics

Art Therapy

Music Therapy

Support Services

Support Workers

Employment Supports

SIL/STA Supports

NDIS Support Coordination

Group Activities

Therapy Lead Groups

Youth Groups

Social Groups