ReferralThe below form is used to refer participant to ADCS. Participant name NDIS Number Date of Birth Participant Email Address Participant Landline Phone Participant Mobile Street address Address line 2 City State Zip / Postal Code Disability type Vision impairment Deaf or hard of hearing Mental health conditions Intellectual disability Acquired brain injury Autism spectrum disorder Physical disability Any other diagnosis? Is this the participant's first plan? yes No Plan Start Date Plan End Date How is the participant's plan managed? * Agency Plan Manager Self Managed Other Transport funding Participant has transport funding within the plan Participant pays transport funding directly to themselves Relationship status Single Married Defacto Other Living arrangements Private rental Family SIL Group home Other Issues with speech Yes No Other Does the participant communicate through a communication board or device? Yes No Other Employment status Employed Unemployed Study N/A Cultural background Indigenous Torres Strait Islander Indigenous/Torres Strait Islander Other Religion Type of service Individual Support NDIS Personal Care Social and Lifestyle Support Social and Community Acces Are there any cultural expectations we should be aware of? Overall aims Interests Walks Beach Movies Music Art Footy Sport Other interests Other relevant information to know about the participant Psychologist Plan Manager Support Coordinator First and Last Name * Support Coordinator organisation Support Coordinator's Email * Support Coordinator's Phone Number Next of kin O/T Behaviour profile Aggression physical or verbal Agitated Alcohol Apathetic Cognitive problems Confused easily Demanding Depression Drugs Eating disorder Extravated Forgetful Frail Hallucinates Hearing impaired Illiterate Incontinent Insomnia Introverted Kleptomaniac Lonely Obsessive Compulsive Pain Paranoid Seizures Sexual Expression Smoker Suicidal Violent Wanders Other behaviour Shift requirements * Preferred days and times * Are supports required on public holidays? Yes No Sometimes Support Worker Preference Male Female No preference Requirements for Social and Community Access To appointments To do shopping To social activities Relationships? Help to make friends Help to improve current relationships Help finding new social groups/activities Help to connect with family Employment and education Support attending current job or studies Support finding a job Support finding a course Send
