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contact us

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ABOUT YOU - Parent/Guardian or Support Coordinator etc.

Please select what describes you best? *

Participant Parent or Guardian Family Member / Next of Kin Support Coordinator Local Area Coordinator Early Intervention Partner Medical Professional

The participant is aware and supportive of me submitting this referral on their behalf.

Yes

First Name

Last Name

Company Name

Email

Phone

How did you hear about Us?

PARTICIPANT DETAILS

First Name

Last Name

Date of Birth

dd-MMM-yyyy Date MUST be in correct format (eg 09-Jan-1995)
Choose a date.

Participant Email

Participant Phone Number

Participant Address

Street Address

Suburb/Postcode

Participant Address - State

Participant Gender

Female: she - her Male: he - him Non-binary: they - them Prefer not to say Other

Is there a legally appointed decision maker for ___? eg. Legal guardian, Power of Attorney etc. *

Yes No

Who will be the ongoing contact person regarding ___'s NDIS Plan and the services they receive?

The Participant The Plan Nominee/Parent or Guardian

Plan Nominee Name

First Name

Last Name

Plan Nominee Emai

Plan Nominee Phone

What is the Plan Nominee's relationship to ___ ___?

Additional Details

NDIS DETAILS

NDIS Plan Number

Plan Start Date

Plan End Date

Please upload your NDIS plan and associated documents here.

Even a screenshot showing your funded supports makes it so much easier and faster
for us to support you. We will never share this without your consent.

SERVICES

Tell us about ___, their primary disability and any other relevant factors.

Tell us about the assessments or therapies that ___ is looking for, to support their goals

Primary Allied Health Service Required

Other Allied Health Services Required

Occupational Therapy Speech Pathology Physiotherapy Behaviour Support Early Childhood Intervention

Do any of the following apply to this referral?

Complex mental health factors mean the clinical intake and needs evaluation process should involve both me as the referrer & the participant directly We're engaging in an appeal process/legal pursuit relating to this referral. Eg challenging a decision/Independent Medical Assessment/tribunal hearing The client has had a laryngectomy or has a tracheostomy of any type None of the above

BILLING

How is the plan funding managed?

NDIA / Agency Managed Self Managed Plan Managed Daglish care will submit a request to be a Provider for ___’s services. They will need to log in to the My NDIS Portal and accept this request.

How is the Behaviour Support / Improved Relationships budget managed?

NDIA / Agency Managed Self Managed Plan Managed

NEXT STEPS

Before we start supporting ___, we’ll contact you as the referrer to get some more information.
Is there anything else important that we need to know at this time?

ABOUT YOU - Parent/Guardian or Support Coordinator etc.

Please select what describes you best? *

Participant Parent or Guardian Family Member / Next of Kin Support Coordinator Local Area Coordinator Early Intervention Partner Medical Professional

The participant is aware and supportive of me submitting this referral on their behalf.

Yes

First Name

Last Name

Company Name

Email

Phone

How did you hear about Us?

PARTICIPANT DETAILS

First Name

Last Name

Date of Birth

dd-MM-yyyy Date MUST be in correct format (eg 09-Jan-1995)
Choose a date.

Participant Email

Participant Phone Number

Participant Address

Suburb/Postcode

State

Participant Gender

Female Male Prefer not to say Other

Is there a legally appointed decision maker for ___? eg. Legal guardian, Power of Attorney etc. *

Yes No

Who will be the ongoing contact person regarding ___'s NDIS Plan and the services they receive?

The Participant The Plan Nominee/Parent or Guardian

NDIS DETAILS

NDIS Plan Number

Plan Start Date

Plan End Date

Please upload your NDIS plan and associated documents here.

Even a screenshot showing your funded supports makes it so much easier and faster
for us to support you. We will never share this without your consent.

SERVICES

Tell us about ___, their primary disability and any other relevant factors.

ell us about the assessments or therapies that ___ is looking for, to support their goals

Primary Allied Health Service Required

Other Allied Health Services Required

Occupational Therapy Speech Pathology Physiotherapy Behaviour Support Early Childhood Intervention

Do any of the following apply to this referral?

Complex mental health factors mean the clinical intake and needs evaluation process should involve both me as the referrer & the participant directly We're engaging in an appeal process/legal pursuit relating to this referral. Eg challenging a decision/Independent Medical Assessment/tribunal hearing The client has had a laryngectomy or has a tracheostomy of any type None of the above

BILLING

How is the funding managed?

NDIA / Agency Managed Self Managed Plan Managed Daglish care submit a request to be a Provider for ___’s services. They will need to log in to the My NDIS Portal and accept this request.

How is the Behaviour Support / Improved Relationships budget managed?

NDIA / Agency Managed Self Managed Plan Managed

NEXT STEPS

Before we start supporting ___, we’ll contact you as the referrer to get some more information.
Is there anything else important that we need to know at this time?

Get in touch with our team!

Get started with your NDIS
journey!

Please select one of the following:

Daglish care

At Daglish Care, we are committed to making it easier for you to access the services you need. Built on a foundation of fairness and flexibility, our team focuses on giving you greater choice and control over your life. We are here to support your journey towards autonomy, ensuring you live life on your terms with the backing of a professional and caring team.

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Daglish care acknowledge and recognise the traditional owners of the land upon
which we live and work, and we pay respect to the elders both past and present.

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