Referral Form

    Intake Risk Assessment Tool

    Client’s Name

    Name of referrer if not client

    Relation and contact number of referrer

    Client’s Date of Birth

    Client’s NDIS Number

    Client’s Address

    Client’s Phone Number

    Intake Assessment

    Personal Details

    Who is the best contact for appointments?



    Preferred method of contact


    Participant Background

    Communication Needs/Supports

    Are there any communication/ behaviour supports in place or required?

    Please complete information regarding the participant including nature of disability, behaviour and support needs

    Cultural Identity

    CALD background?

    Aboriginal or Torres Strait Islander?


    Interpreter required?

    Cultural considerations?

    Supported decision making/legal orders

    Does the client have an authorised person, guardian, or nominee in place?

    What decisions will they be involved in?

    Are there any current legal orders in place?

    Services Request

    Services client wishes to engage

    Primary goals for service

    Is this the client’s first NDIS plan?

    NDIS plan start date

    NDIS plan end date

    Is the support self, plan or agency managed?

    If plan or self managed, where should invoices be sent

    Consent to share a copy of the NDIS plan with?

    Copy of NDIS plan provided?

    Is there a current Behaviour Support Plan in place?

    If yes, has a copy been provided?

    Safety Assessment


    Are you aware of anything that would be a danger to a visiting worker at your residence?


    Do you live with anyone?

    Relationship to you

    Are they ever violent or aggressive towards anyone?

    What type of housing do you live in?

    Is the house number visible from the street?


    Do you have anything in your house that would make it unsafe for workers to visit?

    Do you own any animals?

    Are there any weapons on the property?

    Does anyone smoke on the premises?

    Is there any alcohol or drug use on the premises?

    Is there anything additional you would like to share relevant to services?

    Billing Consent

    Upload NDIS Plan