Make A Referral

My name is:*

First Name Last Name

My Organisation is:*

My phone number is:*

My email address is:*

I prefer that you contact me by:*

Phone
Email

Relationship to the person*

NDIS LAC
NDIS Co-ordinator of Support
NDIS Plan Manager
Medical or Allied Health Practitioner
Educator
ECI partner

Please tell us about the person seeking therapy

Their name is:*

First Name Last Name

Their date of birth is:*

Their address is:*

Street Address (Please insert 40 characters or less) Address Line 2 Suburb State Post Code (Please insert 4 numbers)

What is the name of their contact person?*

What is their relationship to the person?

Parent
Guardian
Carer
Family Member

Hidden

What is their relationship to the person?

Parent
Guardian
Carer
Family Member

Other

What is the contact's phone number?

What is the contact's email address?

Type of therapy required (you can tick more than one box):*

Occupational Therapy
Speech Pathology
Physiotherapy
Positive Behaviour Support
Early Childhood Intervention
Habit Coach

To access Positive Behaviour Support services the participant will need Improved Relationship funding in their NDIS plan. Please select which applies to your client:*

The participant has Improved Relationship funding
The participant does not have Improved Relationship funding
I'm unsure if the participant has Improved Relationship funding

We provide early childhood intervention (ECI) to children aged 0-6 years with NDIS funding. Our ECI services are not available with private health or Medicare funding. Please select which applies:*

The child has an NDIS plan or access to NDIS funding
I’m unsure on funding

Tell us what the person’s goals are and how therapy may support them. You can also tell us what is working or not working for the person at the moment.

Does the person you support have an NDIS plan?*

Yes
No

The following NDIS plan details will enable us to process the referral more efficiently, and help your client access our services faster

NDIS reference number:*

NDIS plan start date:

NDIS plan end date:

How will therapy supports be paid?

NDIS Agency-Managed
NDIS Self-Managed
NDIS Plan-Managed

The details for their plan management agency are:

Organisation

Contact Name

First Name Last Name

Contact Number

Email

Hidden

Address

Street Address (Please insert 40 characters or less) Address Line 2 Suburb State Post Code (Please insert 4 numbers)

What is the amount of therapy funding approved?

Amount of $ approved

Please round to the nearest dollar.

Amount of hours approved

If the person has permitted you to share their NDIS plan with us, please attach a copy below. You can send us a copy of all or part of your plan if you like by attaching it below. (Optional)

Attach here

Drop files here or

Max. file size: 64 MB.

Does the participant have other funding or will they pay privately?

Private
Third Party
Other

Please indicate the participant's funding source in the field below

Is there anything else you would like to tell us?

Hidden

Would you like to receive our monthly ENews, and updates about therapy availability in your local area?

Yes
No

How did you hear about Everyday Independence?:*

Please add the participant's External Client ID/Reference ID*

Other*

After clicking submit, please wait for the confirmation page to appear to confirm your referral has been received. If a confirmation page does not appear please call 1300 179 131

Name

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

Which Best Describes You?

I'm Looking For Therapy For Myself

I’m a Carer / Family Member

Which Best Describes You?

I’m a Carer / Family Member

I'm A Referrer

Our team pushes harder to make inclusion possible for all Australians

Please tell us about the person seeking therapy