SUPPORT COORDINATION
REFERRAL FORM

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Referral Type *

Support CoordinationPsychosocial Recovery CoachSpecialist Support Coordination

REFERER DETAILS

Your Name *

Date *

Relationship *

Organisation

Your Email *

Your Phone Number *

PARTICIPANT DETAILS

 

MrMrsMsMissOther

First Name *

Last Name *

Date of Birth *

NDIS Number *

Phone Number

Email Address

Address *

Street address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Gender *

MaleFemaleNon-Binary / Gender FluidDifferent IdentityPrefer not to say

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CULTURAL BACKGROUND

Country of Birth

Language Spoken

Interpreter Required

YesNo

Communication Method

Spoken LanguageSign LanguageOther Communication Mode

Indigenous Status

AboriginalTorres Strait IslanderAborignal & Torres Strait Islander

Mob or Country

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DISABILITY / MENTAL HEALTH DIAGNOSIS

If known, please specify

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ALERTS

CTO's or AVO's in place, please specify details

Allergies / Medical Conditions

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RISKS

Please select any that apply

DrugsSuicide Self-harmHarm to othersDomestic ViolenceFirearmsVicious Animal/s House in poor condition Other

Note details of others

PARENT / GUARDIAN / PLAN NOMINEE / NEXT OF KIN

Same as Referer

Contact Name

Relationship to Participant

Contact Phone Number

Contact Email

Address if different to participant

GP DETAILS

A GP is an important part of a person's care team, and we may need to communicate with the GP practice if a participant requires additional supports outside of the NDIS plan.

Practice Name

GP Name

Practice Phone Number

Practice Address

NDIS PLAN DETAILS

NDIS Plan Start Date

NDIS Plan End Date

Attach your current NDIS plan

Browse

What is the primary disability recognised by the NDIS? *

Is this a first NDIS plan? *

YesNo

Is there a plan manager? *

YesNo

If yes, please provide details

Are there any recovery goals the participant would like to work on?

ENDORSEMENT OF LOTUS ASSIST

YES - I acknowledge that to endorse LotUs Assist as a PACE provider, Support Coordinator, Recovery Coach and/or Plan Manager, I will need to call the NDIS National Call Centre on 1800 800 110 and state your provider number 4050072073.

HOW DID YOU HEAR ABOUT US

We appreciate you providing us with feedback on how you heard about LotUs Assist *

GP / DoctorAllied Health Professional (e.g., OT, Psychologist, Speech Therapist)Support CoordinatorPsychosocial Recovery CoachLocal Area Coordinator (LAC)NDIA PlannerAnother NDIS Participant / Word of MouthFriend or Family MemberCommunity Organisation or Advocacy GroupOnline Search (e.g., Google)Social Media (e.g., Facebook, Instagram)Our WebsiteNetworking Event or Community ExpoPrevious or Current ClientSchool or Educational ProviderFlyer / BrochureNewsletterDisability Service Directory (e.g., Clickability, MyCareSpace)Other

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