NDIS Client Referral Form | Companion Care Services Kalgoorlie WA

Step 01 / 11 • Referrer Information

Referrer Details

Please enter the details of the person or organisation making this referral.

Name of Referrer *

Referral Organisation

Mobile Number *

Direct Phone / Office

Email Address *

Position / Role

Referrer Postal Address

Step 02 / 11 • Participant Profile

NDIS Participant Details

Personal details, demographics, and living arrangement of the participant.

Participant Full Name *

Date of Birth *

Place of Birth

Gender

Participant Mobile

Home Phone

Residential Street Address *

Suburb *

State

Postcode *

Residential Living Arrangement

Preferred Language

Interpreter Required?

Step 03 / 11 • Plan Management

Participant's NDIS Plan Details

NDIS participant number, funding style, and plan coordination contacts.

Participant NDIS Number

Payment Management

Plan Manager Contact Information

Plan Manager Name / Org

Contact Phone

Invoices Email Address

Plan Start Date

Plan End Date

Upload NDIS Plan Document (PDF, DOC, DOCX, JPG or PNG • up to 15MB)

Click to select file or drag & drop here

Supported formats: PDF, Word (.doc, .docx), or high-res images (up to 15MB)

Step 04 / 11 • Emergency Care

Emergency Contact Person Details

Primary contact person to reach in urgent situations or health events.

Emergency Contact Full Name *

Relationship with Participant *

Mobile Number *

Alternative Phone Number

Step 05 / 11 • Guardianship

Guardian Details

Legal guardian, nominee, or public advocate details (if applicable).

If the participant manages their own decisions independently or guardian details are the same as the emergency contact above, you may proceed to the next step.

Guardian Full Name

Guardian Email Address

Guardian Mobile Number

Guardian Alternative Phone

Step 06 / 11 • Service Selection

NDIS Services Required

Select one or more of our 12 registered NDIS disability support services you would like Companion Care Services to provide.

Step 07 / 11 • Medical Diagnosis

Participant Diagnosis

Please provide details regarding medical, psychological, sensory, or physical diagnoses.

Participant Diagnosis & Relevant Background

Step 08 / 11 • Care Risk Assessment

Participant Risk Assessment

Detailed 5-domain evaluation to ensure safe care delivery and appropriate worker matching.

1. Communication Risk Hearing, Speech, Able to write & English language skills.

2. Cognition Short term memory issues, directions acceptance, time orientation & willingness to participate in support.

3. Mobility Walk unaided, manages stairs unaided, uses walking aid/wheelchair/scooter, transfers independently/with hoist.

4. Personal Care Assistance Required Bed mobility, showering, toileting, grooming, repositioning, mouth care, eating, skin care.

5. Behavioural & Safety Considerations Physical aggression, verbal aggression, self-harm, substance abuse, sexualised behaviour.

Step 09 / 11 • Staff Visiting Safety

Potential Issues For Staff Visiting

Occupational safety and environment factors for support workers attending home visits.

None

No known hazards or visit issues on premises

Pets on the property

Dogs, cats, or unrestrained animals on the premises

Firearms

Licensed firearms stored securely on property

Alcohol or Drugs use

Presence or history of substance use in the home

Others

Other environmental, access, or safety considerations

Step 10 / 11 • Personal Preferences

Anything else we should know?

Tell us about personal likes, dislikes, passions, cultural heritage, or aspirations.

Additional Notes, Personal Preferences & Goals

Step 11 / 11 • Legal Consent & Declaration

Participant Consent Section

Please review and check each declaration statement in accordance with privacy and NDIS regulations.

I understand that the following service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services, in order that I receive the best possible service. I understand that the service must comply with relevant privacy laws and I will contact the organization immediately if I feel that these laws have been breached. Companion Care Services will protect and store all my information in a secure, confidential file, and will not distribute my documents other than the listed services mentioned above. Management has discussed with me how and why certain information about me may need to be provided to other service providers. I understand that recommendation and I give my permission for the information to be shared with the people or agencies as detailed above. I agree with auditing bodies to access my files for review of Companion Care Services Quality assessment.

Client Referral Form