Refer Now Myself | Everyday Independence

Your Details

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First Name*

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Note: Include area code for landline numbers.

Email Address

Date of birth*

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

Do you identify as Aboriginal or Torres Strait Islander?

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How did you hear about Everyday Independence?*

Residential Address

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Services

While we ask what type of therapy you require, Everyday Independence brings a range of complementary team skills to plan and deliver therapy that’s tailored to make the most of your NDIS funding.
Families with children aged up to nine will be supported by an early childhood key worker.

Services required*

Occupational Therapy

Speech Pathology

Physiotherapy

Early Childhood Supports

Positive Behaviour

Functional Assessment

Habit Coach

To access Positive Behaviour Support, the NDIS plan must have funding under Improved Relationships or Behaviour Support.

Do you have Improved Relationship or Behaviour Support funding on your NDIS plan?*

An Early Childhood Key Worker will consult and lead the therapy team (Occupational Therapists, Speech Pathologists, Physiotherapists, Educators and Social Workers) based on your child’s need. You do not need to select any other services. Our ECS services are not available with private health or Medicare funding. In Step 4 please select the funding that applies to your child.

Habit Coaching is offered as part of our therapy package, please ensure another service is selected also.

Tell us about your goals and how we can support you:*

Do you have a practitioner preference?

Male

Female

No preference

Family or Support Contact Details

Please enter your family or support contact details, if relevant.

Support Coordinator?

Support Coordinator

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Plan Nominee?

Plan Nominee

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Who should receive communications relating to updates to appointments, service delivery and waitlists?

Please note the communication recipient must be +18 yrs of age.

Use my details

Use Support Coordinator details above

Use Plan Nominee details above.

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Relationship to you*

Funding Details

The NDIS plan details requested here will enable us to set up your services more efficiently.

Do you have an NDIS Plan?*

Yes

Awaiting Plan Approval

Please call us to find out how you can access our services, if you don’t have a NDIS Plan.

NDIS Number*

Funding Type*

Plan Managed – Organisation name*

Plan Managed – Email*

NDIS Plan Start Date

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

NDIS Plan End Date

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

NDIS Plan

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Please attach a copy of NDIS plan here. Otherwise, you can email this through to referral@everydayind.com.au

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What to Expect

Our Therapies

Work with Us

Requesting Services for Myself

Your Details

Residential Address

Services

Family or Support Contact Details

Who should receive communications relating to updates to appointments, service delivery and waitlists?

Funding Details