Referral – Axoria Care

Referral

Participant Details

Participant Name :

D.O.B:

Gender:

Male Female Other

NDIS Number :

Contact Details(Home) :

Contact Details(Mobile) :

Email

Language Spoken at Home :

Interpreter Required :

Yes No

Preferred Option for Communication :

Email Post Phone

Do you identify as Aboriginal and Torres Strait Islander?

Yes No

Residential Address:

Postal Address (if different from above) :

Is There a Guardianship and/or Administration Order in Place?

Yes No

Is There a Behaviour Management Plan in Place?

Yes No

* Participants under the age of 18, under guardianship or in the care of family or caregivers, please complete below

Name of Parent / Guardian 1:

Primary Carer

Yes No

Lives with Participant

Yes No

Emergency Contact

Yes No

Relationship to Participant

Parent Guardian Caregiver Other

Email Address

Contact Details (Home) :

Contact Details (Mobile) :

Residential Address:

Postal Address (if different from above) :

Name of Parent / Guardian 2:

Primary Carer

Yes No

Lives with Participant

Yes No

Emergency Contact

Yes No

Relationship to Participant

Parent Guardian Caregiver Other

Email Address

Contact Details (Home) :

Contact Details (Mobile) :

Residential Address:

Postal Address (if different from above) :

Disability / Medical Conditions Including any Diagnosis if Relevant.

Title Design

Medication/s Required

Medication Table

MEDICATION ASSESSMENT TOOL	STRATEGIES DEVELOPED	IDENTIFIED IN SUPPORT PLAN
Medication Plan and Consent Form	Yes No	Yes No Please fill out this field.
Medication – Self Medication Assessment	Yes No Please fill out this field.	Yes No Please fill out this field.
Medication Risk Indemnity Form	Yes No Please fill out this field.	Yes No Please fill out this field.

Title Design

Behaviour Support

Behaviour Support Plan Documents Collected for Authorisation Purposes (if relevant)

Yes No

Behaviour Support Plan Available on NDIS Portal?

Yes No

* Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

Name :

Phone number :

Email :

Frequency of use:

Address:

Name :

Phone number :

Email :

Frequency of use:

Address:

Title Design

Health Care Information

Medicare Number :

Expiry Date :

Reference Number :

Private Healthcare Provider :

Membership Number :

Reference Number: :

Doctor Name :

Phone Number :

Address:

Title Design

Funding

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

Phone Number :

NDIS Date:

Self-Managed Plan Managed

Please Provide Details for Invoices

Name:

Email :

Comments :

Title Design

Preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communication Device

Physical Assistance

Other Considerations

Title Design

Goals and Aspirations

Heading

What do you want to achieve for yourself – life skills, physically, socially etc?

Immediately

In 6 months

Next year

Title Design

Risk Assessment

Risk Assessment

RISK ASSESSMENT TOOL	STRATEGIES DEVELOPED	IDENTIFIED IN SUPPORT PLAN
Individual Risk Assessment Profile	Yes No	Yes No
Safety Environment Checklist – Home	Yes No	Yes No
Participant Safe Environment Risk Assessment	Yes No	Yes No
Nutrition and Swallowing Risk Checklist	Yes No	Yes No

I understand that:

This organisation owns these records.
Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
I can ask to see records and receive a copy
Records are archived for a set period according to policy and procedure
I understand that all information obtained will be kept confidential.