REFERRALS Disability Services Disability Services First Name Last Name NDIS Plan Number NDIS Plan Start Date NDIS Plan End Date Gender Please Select Male Female Non-Binary Intersex Prefer Not To Say 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 to locate Accommodation Respite 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 Enduring Power of Attorney Public Trustee 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 Who is Completing the Referral The Client/Myself Carer/Representative Support Coordinator Agency Advocate Other Full Name of Person Completing the Referral Agency/Company Role Email: Phone Number 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
