Referral form - Support Coordination

Please complete this document when referring for Support Coordination

Upon receipt of your completed referral form, unless we need to discuss any of your responses with you first, our Client Relationship Team will develop a Service Agreement for you based on the answers you provide. The hours of the agreement are based on the NDIS funding provided in your NDIS Plan. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

If you would like any assistance with completing this form, please contact our team on 08 8379 6976 or at contactus@autismsa.org.au

Participant first name *

Participant last name *

Preferred Name

Date of birth (dd/mm/yyyy) *

Address *

Suburb *

Post Code *

Phone number *

Email Address *

Caregiver name (if applicable)

Caregiver phone number (if applicable)

Caregiver email (if applicable)

Person completing this form ( if not the participant or caregiver)

Contact details

Relationship to the particpant

Do any of the following apply to the client *

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderNot applicable

Please provide further detail *

Please select from the below *

I would like contact to discuss the services furtherI understand the services being provided and do not need to speak to anyone (place me on the waitlist)

About the Participant

Pronouns *

He/himShe/herThey/themOther

Other *

Preferred Terminology *

autistic/autistic personperson with autismperson on the spectrum/ autistic spectrum Other

Other *

What is the participant's Diagnosis *

No DiagnosisAutism Spectrum DisorderPhysical DisabilityHearing/Vision impairment (please advise in comment box below)Seizure/Heart Condition (please advise in comment below)ADHDOther (please advise in comment box below)

Please advise the participants diagnosis *

Communication

How does the participant communicate? *

Please provide the participants individual communication requirements *

Does the client require an interpreter? *

YesNo

Provide details *

Services and Support

Please provide other support *

NDIS Funding Information

NDIS Support Coordination Funding *

Level 2 - Support CoordinationLevel 3 - Specialist Support Coordination

Number of hours or funding amount

Please attach a copy of your NDIS plan

Browse

NDIS Plan number *

NDIS Plan Start Date *

NDIS Plan End date *

Plan Nominee ( if applicable )

Is your Plan *

Self ManagedAgency ManagedPlan Managed

Plan Manager Name *

Plan Manager Email

Is this a PACE plan

YesNoUnsure

Location Preferences *

Autism SA Tonsley ClinicAutism SA Elizabeth ClinicOnline (telehealth)