REFERRAL - Where Compassion Meets Passion

Services

Which service do you require?

NDIS Participant New Application for NDIS

Who requires support?

Myself Clients Family, friends or relatives

General Information

Participant Full Name (IN CAPITAL)

Gender Identity/Known Pronouns

Date Of Birth

Enter your e-mail

Repeat to confirm

Enter you contact number

Location/ Where do you need the support?

Street address

Address line 2

City

State

Zip/Postal code

Pets

Please fill the form below

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?

Transportation

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.

Health services

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 have any chronic conditions that necessitate ongoing nursing support?

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

Risk Assessment and Guidance

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?

Heavy drinker

Hard Drug User

Heavy Smoker

Other

None

Previous treating Clinicians

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

Client reports

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

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Referral form

Services

Which service do you require?

Who requires support?

General Information

Participant Full Name (IN CAPITAL)

Gender Identity/Known Pronouns

Date Of Birth

Enter your e-mail

Repeat to confirm

Enter you contact number

Location/ Where do you need the support?

Street address

Address line 2

City

State

Zip/Postal code

Pets

Support

What supports are you interested in

How do you intend to pay?

Diagnosis

Primary diagnosis

Additional health concerns

Are there any other health concerns or conditions?

Important Medical History

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

Please fill the form below

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?

Transportation

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.

Health services

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 have any chronic conditions that necessitate ongoing nursing support?

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

Risk Assessment and Guidance

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?

Previous treating Clinicians

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

Client reports

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

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