Referral Form Name * First Name Last Name Date of Birth Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Client Representative Details (If Applicable) Name First Name Last Name Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country NDIS Details Plan * Plan Managed Self Managed Agency Managed Plan Manage Name (if applicable) First Name Last Name Plan Manager Agency (If Applicable) NDIS Number * Available/Remaining Funding for Capacity Building Supports * Plan Start Date * MM DD YYYY Plan Review Date * MM DD YYYY Client Goals (As stated in the NDIS plan) * Referrer Details (Person Making the Referral) Name * First Name Last Name Agency Role Email Phone (###) ### #### I have obtained consent from the participant to make this referral and provide LM Therapy with the participant's personal and medical details. * Yes No Reason For Referral Therapeutic Supports Forensic Supports Positve Behavioural Support Support Coordination Life Skills Supports Others Reason for Referral/ Relevant Medical Information * Accommodation Type Permanent Temporary Support Independent Living Accommodation (SIL) Public Housing Who normally lives with you? Do you usually require a carer or assistance in moving around the property? Are there any behaviours of concern or plans we should be aware of? Within the last 4 weeks has your behaviour injured anyone, even accidentally? When you feel overwhelmed, have you ever found yourself making threats against others? Do you have any legal orders in place which restrict what you do? If so, can you provide detail? Will someone be home to open the front door? Who should the clinician contact upon arrival? Will I see your property from the street? Is there parking close to your property? Is there level access to your property? Is there mobile phone coverage at your property? Where is the best access to your property? Do you have any animals at the property? Do you have any weapons at the property? Does anyone smoke or vape at the property? Is there alcohol or drug use on the property? (e.g., does anyone in the home drink lots of alcohol) Is there anything else we need to know before attending your property? Is there anyone at the property with a contagious illness? Does visiting your property present any risks or danger to visitors? (e.g., does anyone in the home display behaviours of concern or act aggressively) Does anyone in the home have a current DVO, AVO, Protection Order or Restraining Order against them? Does anyone in the home have a history of sexual offences? Thank you for submitting your referral to LM therapy. We will endeavor to respond to your referral requests as soon as possible.
