Expression of interest
Participant Details
First Name
*
Last Name
*
Date of Birth
*
Phone Number
*
Email Address
Street Address
*
City
*
State
*
Postcode
*
Client Representative Details (If Applicable)
First Name
Last Name
Phone Number
Email
Street Address
City
State
Postcode
Preferred contact type
*
Email
Phone call
Text
In person
Best contact time
*
Monday
Tuesday
Wednesday
Thursday
Friday
Comments for contact time
*
NDIS Details
Plan
*
Plan Managed
Self Managed
Agency Managed
Private funding
Plan Manager Name (If Applicable)
Plan Manager Agency (If Applicable)
NDIS Number
*
Available/Remaing Funding for Capacity Building Supports
Plan Start Date
*
Plan Review Date
*
Client Goals (As stated in the NDIS plan)
*
Referrer Details (Person Making the Referral)
First Name
*
Last Name
*
Agency
Role
Email Address
*
Phone Number
*
I have obtained consent from the participant to make this referral and provide 3 Minds Qld with the participant's personal and medical details.
*
Reason For Referral
Type of service
*
Holiday program
SLES
Support Coordination
In home support
Community access
Before and after school support
Centre-based support
Over 16 social program
Under 16 social program
Under 10 social program
Personal care
Medication support
Restrictive practices
Days of service
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
School holidays
Support requirements
*
1:1
1:2
Mix of both
Reason For Referral/Relevant Medical Information
*
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