HEDSS NDIS Referral Application

Participants details

Participants name(Required)

First Middle Last

Date of birth(Required)

DD slash MM slash YYYY

Participants gender(Required)

Participants address(Required)

Street Address Address Line 2 City State Postcode

Participants phone number

Participants email address

Preferred contact method

Primary contact

NDIS number

Plan start date

DD slash MM slash YYYY

Plan end date

DD slash MM slash YYYY

Referrer details

Who is completing this form?(Required)

Referrer name(Required)

Referrer phone(Required)

Referrer email(Required)

Have you been given permission to share participants information?(Required)

Yes

Plan nominee (if applicable)

Plan nominee full name

Nominee phone

Nominee email

Emergency contacts

Primary emergency contact(Required)

First Last

Primary emergency contact relationship(Required)

Primary emergency contact phone(Required)

Primary emergency contact address(Required)

Street Address Address Line 2 City State Postcode

Secondary emergency contact

First Last

Secondary emergency contact relationship

Secondary emergency contact phone

Secondary emergency contact address

Street Address Address Line 2 City State Postcode

Does the client require assistance in an emergency?

Yes

Emergency assistance description

Participants Supports

Formal and Informal supports

List the Formal and Informal supports the participant has in place. E.G: Family/Friends, Therapists, Coordinator of supports:

Name / Organisation

Describe the support provided

Do you consent to HEDSS sharing information with these people?

Yes

Support Details

How many support hours required weekly?

Support Frequency

Weekly

Fortnightly

Monthly

As Required

Preferred Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Support Times

Mornings

Midday

Afternoon

Evenings

Participant Support Details

Support Requirements

Please List Support Requirements

Community Participation

Household Chores

Transport

Budgeting

Decision Making

Self-Care/Personal Hygiene

Attending Appointments

Communication/Auslan

Participant Likes/Interests

Participant likes

Shopping

Socialising

Music

Cooking

Animals

Reading

Colouring and drawing

Dancing

Driving/Cars

Fishing

Swimming

Walking

Gym

Movies

Computers

Games

Participant other likes

List other activities

Participant Dislikes

Participant dislikes

List participant dislikes

Participant Goals

Participants Goals

List Participants Goals

Cultural and Religious Considerations

List Cultural and Religious Considerations

Diagnosis Information

Diagnoses

Does the participant have any of the following diagnoses?

Epilepsy

Allergies

Diabetes

Asthma

All diagnoses the client has

List all diagnoses the client has

Health Information

Medication required

Is medication required?

Yes

Medication details

Prompt required

Is prompt required?

Yes

Prompt details

Assistance required

Is assistance required?
(This includes full or partial physical assistance)

Yes

Assistance details

Administration required

Is administration required?

Yes

Administration details

Allergies

Does client have Allergies?

Yes

Allergies details

Does the participant require assistance with High Intensity Personal Care activities?

Yes

High Intensity Personal Care details

Mobility issues

Does the person have any mobility issues?

Yes

Mobility details

Aids required

Are there any aids required?

Yes

Aids details

Schedule of Support

Are there any current support plans in place?

Yes

Can you provide support plan documents?

Yes

File

Drop files here or

Accepted file types: docx, doc, pdf, txt, rtf, odt, jpg, png, Max. file size: 1 MB.

Please upload any relevant assessments/reports completed for participant.

If no support plans can be shared, please fill out the below

Current support plan Monday

Monday

Current support plan Tuesday

Tuesday

Current support plan Wednesday

Wednesday

Current support plan Thursday

Thursday

Current support plan Friday

Friday

Current support plan Saturday

Saturday

Current support plan Sunday

Sunday

Participant Risk

Are there any risks associated with supporting this participant in the community?

Yes

Community Description of Risk/s

Community Risk Level

Risk Level

High

Medium

Low

Community Risk Action Required

Are there any risks associated with supporting this participant in the home?

Yes

Home Support Description of Risk/s

Home Support Risk Level

Risk Level

High

Medium

Low

Home Support Action Required

Does the participant have a history of criminal activity?

Yes

Criminal Activity Description of Risk/s

Criminal Activity Risk Level

Risk Level

High

Medium

Low

Criminal Activity Action Required

Will HEDSS have to implement Authorised Restrictive Practises for this participant?

Yes

Restrictive Practises Further details

Funding Details

The available funds to be used are

If Self-Managed, please provide the details for who/where to direct our invoices to

Self-Managed Invoice Recipient

First Last

Self-Managed Contact Phone

Self-Managed Contact Email

If Plan-Managed, please fill out the below

Plan Manager Name

Plan-Managed Contact Phone

Plan-Managed Contact Email

(HEDSS will not book out any funds until a Service Booking has been signed by participant or plan nominee)

Support Category 1

Support Category 1 amount allocated

Current funding amount allocated for HEDSS supports category 1

Support Category 2

Support Category 2 amount allocated

Current funding amount allocated for HEDSS supports category 2

Consent to Share Information

I Consent to Share Information

By signing below you are consenting to HEDSS sharing information with stakeholders nominated within this agreement and HEDSS for the purpose of finding appropriate supports. You can withdraw this consent at any time in writing by emailing us at admin@hedss.com.au

Comments

This field is for validation purposes and should be left unchanged.

Referral application

Participants details

Referrer details

Plan nominee (if applicable)

Emergency contacts

Participants Supports

Support Details

Participant Support Details

Participant Likes/Interests

Participant Dislikes

Participant Goals

Cultural and Religious Considerations

Diagnosis Information

Health Information

Schedule of Support

Participant Risk

Funding Details

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