Referral & intake

Let’s get to know you.

Participants, families, support coordinators and plan managers can all refer. Fill in what you can, and our team will be in touch to talk through the next steps. It takes about 10–15 minutes.

Referrer
Participant
Plan
Services
Goals
Risk
Documents

1 About the person making the referral

I am a… * Your name * Organisation (if applicable) Relationship to participant Email * Phone *

2 About the participant

Full name * Preferred name Date of birth * Gender Home address * Phone Email Living arrangement Who else lives in the home? Primary disability / diagnosis * Other health conditions How does the participant communicate? Language spoken at home Interpreter required? Aboriginal and/or Torres Strait Islander? Cultural, religious or other considerations Interests, hobbies and what’s important to them What does a good day look like? Any routines, likes and dislikes we should know? Who makes decisions? Guardian / nominee name & contact (if applicable) Emergency contact name * Emergency contact phone * Emergency contact relationship

3 NDIS plan

NDIS number How is the plan managed? * Plan start date Plan end date

4 Services requested

Preferred support worker gender Preferred days / times Hours of support per week (if known) Preferred start date

5 Goals

What would the participant like to achieve? Add up to 10 goals, ideally from their NDIS plan.

Goal 1 *Goal 2Goal 3Goal 4

6 Risk assessment

This helps us keep the participant and our workers safe, in line with NDIS Practice Standards. Answer as best you can. Your answers are confidential.

Home & environment

Health, behaviour & wellbeing

Anything else that may affect the safety of the participant or our workers?

7 Supporting documents

Attach any reports that will help us understand the participant’s needs. PDF, Word or photos. Up to 8 MB in total. If your files are larger, send them to enquiries@yourmatecare.com.

NDIS plan Occupational therapy (OT) report Speech pathology report Behaviour Support Plan (BSP) Psychology / medical report Other document

Total attached: 0.0 MB of 8 MB

The participant (or their legal representative) has consented to this referral, to sharing this information and to YMCS contacting them, in line with the Privacy Policy. *