NDIS Disability Support Referral Form

Referrer Information

Full Name *

Organization *

Position/Title *

Email Address *

Phone Number *

NDIS Participant Information

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

NDIS Number *

Home Address *

Client has a Representative (Guardian, Power of Attorney, or Support Person)

NDIS Support Requirements

Plan Management Type *

Available Remaining Funds

Optional - in AUD

Plan Start Date *

Plan Review Date *

NDIS Support Categories Required * (Select all that apply)

Preferred Support Worker Gender

Urgency Level *

Primary Disability & Support Needs *

Client Goals *

Current Support Network

Supporting Documents

NDIS Plan *

Upload the participant's current NDIS plan (required)

Medical/Allied Health Reports

Upload relevant reports from medical professionals, therapists, or behavior specialists

Additional Information

Consent and Authorization

I confirm that I have the participant's (or guardian's) consent to make this referral and that all information provided is accurate to the best of my knowledge. *

I acknowledge that this information will be used for NDIS service delivery and may be shared with relevant support coordinators and allied health professionals as necessary. *

What Happens Next?

Plan Review

Our team will review the NDIS plan and assess available funding within 24 hours.

Service Agreement

We'll prepare a service agreement outlining support delivery and coordinate with the participant's support coordinator if applicable.

Support Commencement

We'll match the participant with appropriate support workers and commence services according to their goals and preferences.

Aboriginal and Torres Strait Islander cultural imagery

Acknowledgment to Country

Clinicare QLD acknowledges the First Peoples of this Nation and their ongoing cultural and spiritual connections to the lands, waters, seas, skies, and communities.

We acknowledge First Nations Peoples as the Traditional Custodians and Lore Keepers of the oldest living culture and pay respects to their Elders past and present.

Unity in Diversity • Respect • Recognition