Referal Form

Participant Details:

Interpreter required

Yes

Cultural Background:

Aboriginal

Torres Straight Islander

ATSI

Neither

Refugee

Asylum seeker

Current Living Environment:

Public Housing

Private Rental

In Hospital

Temporary Housing

Homeless

Asylum seeker

Next of Kin / Guardian

Guardianship Order:

Yes

Financial Management Order

Yes

Date of Order & Expiry

Support Coordination:

Yes

Contact Details

Copy of Current Plan Provided:

Yes

Plan Managed

Agency Managed

Plan Manager Name

Plan Manager Email

Plan Manager Phone Number

Support Required:

Other Co-existing Health issues:

Mental Health Issues:

Please give us a summary of care needs, risks/concerns:

CONSENT

I Agree

Consent- Referrer use only
I have discussed the proposed referral with the Participant being referred or authorized representative and I am satisfied that they understand the proposed uses and disclosures, and has provided their informed consent to these.

Terms and Conditions

I acknowledge that the information provided is true correct. I agree that BB Disability and Health Services may contact my health service providers to gather additional information to assist with my referral if needed. I consent to this referral being submitted for the consideration of BB Disability and Health Service’s Residential accommodation services and Community services.

Given Name

If a Guardian is appointed, provide a copy of the Guardianship Order issued by NCAT

Last Name

Date

Guardians Given Name

Last Name

Date

If you have a Guardian, please email your completed form to them to sign and email it back to you. Once you’ve received the signed copy back, please email the form to your healthcare professional to finalise and submit.

What Happens next?

Please submit the referral to admin@bbdisability.com.au One of the Team Members will contact you to discuss the service options as quickly as possible. You can contact us on 1300 070 724

Referrer's Details:

Participant Details:

NDIS Plan Details:

Current Supports:

CONSENT