REFERRALS Disability Services Disability Services First Name Last Name Date of Birth Gender Please Select Male Female Non-Binary Intersex Prefer Not To Say NDIS Plan Number NDIS Plan Start Date NDIS Plan End Date Aboriginal or Torres Strait Islander Please Select Yes No Prefer Not To Say Please List Primary Language Do you require an Interpreter: Yes No Client Address Street Address Suburb State Postcode Client Phone Number Client Email Address Primary Diagnosis/Disability, Medical Conditions or Relevant Medical Information I am looking for Supported Independent Living (SIL) 24/7 Independent Living Options Assistance with Daily Activities Domestic Assistance Community Access Household Tasks Transport Other If other please specify: I am funded for: SIL Shared Living 1:1 SIL Shared Living 1:2 SIL Shared Living 1:3 ILO 10-12hrs daily ILO 7-10hrs daily Respite I am not yet funded for Supported Living I pay privately (or from my pension) If other please specify: Additional Comments Carer, Guardian or Representative Information Full Name of Person Completing the Referral Phone Number Email Nature of Relationship (select all that apply): Carer/Family Informal Guardian OPG or Appointed Guardian Support Coordinator Specialist Support Coordinator Enduring Power of Attorney Public Trustee Nominee Advocate Other Agency or Organisation (if relevant) Street Address Suburb State Postcode Preferred Contact Method Phone Email Mail NDIS Plan Type: Plan Managed Self Managed NDIA Managed Not Sure Plan Manager's Name: Plan Manager Agency (If Applicable) Plan Manager's Phone Number Plan Manager's Email (for sending invoices) Client Goals (as stated in NDIS Plan) Please upload a copy of the current NDIS Plan Consent: I have obtained consent from the participant to make this referral and provide Glory Care with the participant's personal and medical details. I am authorised to act on behalf of the Client and can provide a copy of that authorisation. I am representing myself (I am the Client). Submit
