Refer A New Participant Does this referral require urgent follow up? *YesNoIs the participant aware of this referral being made? *YesNoWhen would the participant like services to commence?What is the reason for referring this participant to Independence World?Enter details for the participant being referredPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First NameLast NamePreferred NameGuardian (if applicable)Date of BirthGenderMaleFemaleNon-BinaryOther IdentificationPreferred LanguageTranslation is required for English communicationWhat's the preferred method for contacting participant? *Phone CallSMSEmailPhoneEmail AddressStreet Address *Apartment, suite, etcSuburbState/ProvinceZIP / Postal CodeDisabilityOther ConditionsComplications with conditionsEnter details for the person referring the participant (you)PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First NameLast NameWhat is your relationship to the participant being referred?Phone *Email Address *Name of Agency (if applicable)Is the participant part of the NDIS? *YesNoHow is the plan managed? *NDIA managedSelf-managedPlan managedOtherWe do not support NDIA managed participants. Further progress is not possible at this time. Thank you for your understanding.Other detailsPlan Manager Name *Plan Manager Email *NDIS Participant/Plan Number *Plan Start/End Dates *Support Item Number and Support Item Name (according to NDIS price Guide) *-01_011_0107_1_1 Assistance With Self-Care Activities - Weekday Daytime $65.00/hr04_104_0125_6_1 Access Community Social and Rec Activ - Weekday Daytime $65.00/hrSupport Item Number and Support Item Name for Transport to be used (according to NDIS price Guide) *-01_799_0104_1_1 Provider travel - non-labour costs $1.00/km01_799_0107_1_1 Provider travel - non-labour costs $1.00/km01_799_0120_1_1 Provider travel - non-labour costs $1.00/km04_590_0125_6_1 Provider travel - non-labour costs $1.00/km04_799_0125_6_1 Provider travel - non-labour costs $1.00/kmIs the participant high risk? *YesNoDescribe the participantinclude details such as formal diagnosis, personality traits, occupation or anything else deemed necessaryShort Term Goals0 / 300Long Term Goals0 / 300What is the living situation?Living aloneLiving with familyShare accommodationRespite careOther living situationDescribe living situationAdditional information regarding living arrangements?Any pets, animals or other dependants, if it is high-rise apartment with elevators or security gates etc.Please rate the participant on the below factors: Very Poor ExcellentCognition/Awareness12345Communication12345Mobility12345Physical Health12345Mental Wellbeing12345What Mobility Aids does the participant use?Manual HoistWalking Stick/FrameManual WheelchairPowered WheelchairShower ChairProstheticsSupport InfrastructureStair LiftOtherSelect all that applyInclude Details:What Personal Care requirements does the participant have?Domestic DutiesShower/Toilet AsisstancePhysio/ExerciseMeal PreparationCommunity AccessAnimal CareGardeningTransportMedical AssistanceOtherSelect all that applyInclude Details:What preferences does the participant have for their disability support worker?i.e. male or female, particular skills requiredHow many hours of support is needed per week?Does the participant require public holidays?NoEnquire when public holidays are upcomingAlways requiredWhat days and times will be required? Or are times flexible?i.e. Flexible Hours. (Or Monday: 1pm - 8pm / Tuesday-Friday: 7am - 3pm)Upload Participant DocumentsDrag and Drop (or) Choose FilesAdd any necessary documentsReview SubmissionDoes this require urgent follow up? {radio-1}Is the participant aware of this referral? {radio-2}Commencement Date: {text-15}Reason for referral: {text-19} Participant Details Participant Name: {name-1-prefix} {name-1-first-name} {name-1-last-name}Preferred Name: {text-17}Guardian: {text-18}Date of Birth: {text-14}Phone: {text-12}Participant Address: {address-1-address_line} {address-1-street_address}, {address-1-city}, {address-1-state} {address-1-zip}Gender: {select-1}Preferred Language: {text-1} {checkbox-1}Email: {email-1}Preferred Contact Method: {checkbox-2} Participant Information Disability: {text-10}Other Conditions: {text-16}Condition Complications: {text-20}Participant Description: {textarea-2}High Risk: {radio-5} |Risk Level: {number-1}Living Situation: {select-2} | Other Details: {text-5}Notable Living Arrangements: {textarea-3}Cognition: {radio-6}Communication: {radio-7}Mobility: {radio-8}Physical Health: {radio-9}Mental Wellbeing: {radio-10} Support Requirements Mobility Aids: {checkbox-15} {text-6}Personal Care Needs: {checkbox-16} {text-7}Support Worker Preferences: {text-23}Hours Per Week: {text-11}Does the participant require public holidays? {select-5}Days and Flexibility: {textarea-6}Short-Term Goals: {text-21}Long-Term Goals: {text-22} Plan Details Has NDIS Plan: {radio-3}Plan management: {radio-4} {text-4}Plan manager: {name-3}Plan manager email: {email-3}NDIS Plan Number: {text-8}Plan Start/End Dates: {text-9}Support Item Number and Support Item Name: {select-3}Support Item Number and Support Item Name for Transport: {select-4} Referrer Details: Name: {name-2-prefix} {name-2-first-name} {name-2-last-name}Relationship to participant: {text-2}Phone: {text-13}Email: {email-2}Name of Agency: {text-3} Uploaded Documents: {upload-1}Confirm and Submit
