NDIS Referral - Adapt Health Care

Make an NDIS Referral

If you are ready to make a referral, please fill in the below NDIS Referral Form.

If you wish to make an Aged Care Referral, head to this page.

If you are making a general enquiry or want some advice on how we can help, please fill in the ‘Contact Us‘ form.

We look forward to speaking with you soon.

Please fill in the Home Safety Screen to the best of your knowledge and upload the completed document as part of the Referral Form. This procedure is in place with our community staff safety in mind.

Similarly, please complete the NDIS Statement of Supports and upload it (where prompted) in the below Referral Form.

We have also attached our Service Agreement for your and your client’s perusal. If they have the time, they can fill this out prior to our therapist commencing services. Otherwise, this can be completed during the initial. Following the initial, our therapist will complete a schedule of supports outlining the hours and funding required to provide supports to reach their goals.

NDIS Referral Form

Are You Submitting This Referral For Yourself?(Required)

Yes

About the person being referred:

Client Name(Required)

First Last

Client Date of Birth(Required)

Client Phone Number(Required)

NDIS Number(Required)

Plan Date: Start(Required)

Plan Date: Review(Required)

Email(Required)

Enter Email Confirm Email

Client Address(Required)

How is the Plan Managed?(Required)

Service/s Required?(Required)

Occupational Therapy

Dietetics

Physiotherapy

Exercise Physiology

Podiatry

Speech Pathology

Reason for Referral?

Who is the Decision Maker?(Required)

Decision Maker Name(Required)

First Last

Decision Maker Email(Required)

Enter Email Confirm Email

Phone Number(Required)

The following information will help us to quickly match your participant with a suitable therapist. If known, please provide the following:

Primary Diagnosis

Other Diagnoses - Please Specify

(e.g. Mental health diagnosis, intellectual disability, physical disability, Autism Spectrum disorder etc.)

Other Background Context About the Client

Attach NDIS Plan

Drop files here or

Max. file size: 32 MB.

Attach NDIS Statement of Supports(Required)

Drop files here or

Max. file size: 32 MB.

Attach Home Safety Checklist(Required)

(Checklist available for download above this form).

Max. file size: 32 MB.

Attach Service Agreement(Required)

(Agreement available for download above this form).

Max. file size: 32 MB.

Please state the NDIS participant's NDIS Goals:(Required)

Referrer Details (the person filling out this form):

Referrer Name(Required)

First Last

Referring Company

Referrer Email(Required)

Enter Email Confirm Email

Referrer Phone Number(Required)