Referral form - Work my Way

WORK MY WAY

The Work My Way employment program is a job ready program that offers pre-employment skills, career exploration, and hands on practical work experience, specifically designed for school leavers and adults who wish to seek meaningful employment.

Work My Way features modules tailored to the specific needs of participants, designed to build skills and confidence as they commence the pathway to employment.

Complimenting our customised employment modules, participants will receive one to one support to guide them toward successful outcomes.

Work My Way can be funded by NDIS (CB Finding and Keeping a Job budget) or fee for service (out of pocket).

Participant first name *

Participant last name *

Gender *

Date of birth (dd/mm/yyyy) *

Suburb *

Post Code *

Phone number *

Email Address *

Caregiver name (if applicable)

Caregiver phone number (if applicable)

Caregiver email (if applicable)

What is your preferred method of communication?

PhoneEmailSMSAny

About the Participant

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 *

How does the participant communicate? *

VerbalGesturesUse of ACC

Literacy (please select as many as you feel are relevant)

I need support with writing I need support with reading I can write independently I can read independently

What are the known barriers to employment that require support

Other barriers to employement *

Are there any behaviours of concern? *

No behaviorsSelf-Harm or Harm of others (please specify)Other (please specify)

Other (please specify) *

Does the participant have any specific interests that they enjoy? * *

YesNo

If yes (please describe interests below) * *

Does the participant have any allergies? * *

YesNo

If yes (please describe allergies below)

Is there any other information you would like us to know about the participant? *

Registration

How much will it cost?

Program cost is $474.78 per week
Each week comprises of a group collaboration session and individualised support designed around the NDIS Goals of the particpant
The cost of the program is in line with NDIS rates and is subject to change in line with price increases

Please indicate whether you will be funding the group by NDIS or Fee for Service (FFS) *

NDISFee For Service

The CSI Group Progams are funded by Finding and Keeping a job - School Leavers Employment Supports. Please tick the box to confirm you have the available funding for this program *

NDIS Plan number *

NDIS Plan Start Date *

NDIS Plan End date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

Is your Plan *

Self ManagedAgency ManagedPlan Managed

Plan Manager Name *

Plan Manager Email

Photographic/Video Release Authority

I grant Autism SA, its representatives, employees and suppliers the right to take/use photographs/videos of myself and/or my child/children and my property during attendance at the above-identified eventfor use in marketing collateral such as annual reports, publicity materials, advertising, social media and web content.It can also include paragraphs.

Response *

Yes, I grant Autism SA the rights aboveNo, I do not grant Autism SA the rights above

I have read and accept the Terms and Conditions of this service, including the cancellation policy *

I have adequate funding available under my Core Funding - Community Social and Economic Participation Budget, and this does not expire during the dates I wish to book *

Please Sign *

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