Referral - Where Compassion Meets Passion

Referral form

Which service do you require?

Who requires the support?

Participant Full Name (IN CAPITAL)

Gender Identity/Known Pronouns

Date Of Birth

Enter your e-mail

Repeat to confirm

Enter you contact number

Street Address

Address Line 2

City

State

Zip/Postal Code

Pets

What supports are you interested in

High-Intensity Nursing Care; IDC and SPC change, wound dressing etc. Support Workers and Carers Assistance with Travel and Transport Household Tasks: Housekeeping Meal Preparation Group activities such as group art therapies and group sound healing Implementing Behavioral Support Plan Assistance to Access and Maintain Employment or Higher Education Development of Daily Living and Life Skills/Transitions

How do you intend to pay?

Diagnosis

Are there any other health concerns or conditions?

Can you share any important medical history or past health events that are relevant?

NDIS Number (If Applicable)

Plan Start Date

Can you share details about the participant's support history and any specific needs? For instance, do they have experience with support workers? Are there preferences for attributes like age, gender, or personality traits?

Does the participant need transportation to any appointments with their support worker?

Does the participant want Lotus Embrace to include support on public holidays in the quote, or would they prefer to cancel support for those days?

Does the participant want Lotus Embrace to include group activities in the quote, charged at NDIS price guide rates? Prices may vary depending on the number of participants.

Does the participant use any special equipment or devices that need nursing help during daily tasks?

Does the participant need nursing help with any personal care or hygiene tasks every day?

Does the participant have any special dietary needs that nursing staff need to help with?

Does the participant need nursing staff to handle medication management on a daily basis?

Does the participant have any chronic conditions that necessitate ongoing nursing support?

Are there any behavioral concerns or risks posed by clients?

What are the triggers for these behavioral concerns ? (if any)

What guidance should support workers follow when responding to such situations? (if any)

Any participant's drug habits or history with substance use?

Please share contact info for therapists or other professionals in case our support team needs their help.

Please share up to three relevant reports (e.g., psychology, occupational therapy) for our support workers to have a thorough understanding of the client.

Referral form

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