New Client Referral Form – Illawara Therapies

About You

What services are you referring for? *

Art Therapy
Early Childhood Supports
Positive Behaviour Practitioner
Massage Therapy

Your Name *

First

Last

Your Company/Business *

Your Email *

Your Phone Number *

Your preferred method of communication for our initial contact *

Phone
Email
By Mail/Letter to participant's address

Your role *

If you are a participant, or a parent/guardian or carer who is helping a participant apply, please use our New Client Intake Form (Link at top of page).

How did you hear about Illawarra Therapies?

About the Participant

Participant's Funding Type: *

NDIS Plan - Self Managed
NDIS Plan - Plan Managed
NDIS Plan - Agency Managed
Not NDIS - Private Client

Participant's NDIS Details *

First

Last

If the participant is on an NDIS Plan, please provide the details above. Skip this step if they are a private client applicant.

Plan Manager Details *

First

Middle

Last

If the participant is on an NDIS Plan, please provide the details above. Skip this step if they are a private client applicant.

Participant's Name *

First

Last

Participant's Date of Birth *

School (if under 18)

Parent/Guardian/Carer's Name *

First

Last

Home Address (for service) *

Languages spoken at home *

Will they require an interpreter? *

Yes
No

Best Email *

This is the email address of the:

Participant
Parent/Guardian or Carer

Best Phone Number *

This is the phone number of the: (copy)

Participant
Parent/Guardian or Carer

About the Therapy

Current NDIS Goals (where applicable)

You can provide a copy of the participant's goals by emailing their NDIS Plan to us, or copy and paste the goals from their plan here.

Personal Interests

Let us know more about the participants personal interests.

Strengths

Let us know more about the participants strengths.

Areas for Development

Let us know if there are areas of concerns (such as behaviours, safety etc) where the participant may need help and support when in the community, school or at home?

Current Allied Health Supports

Who are they currently using for services such as Art Therapy, Positive Behaviour Practitioner, Speech Therapy, Occupational Therapy, Exercise/Physio etc?

Former Allied Health Supports

Who were they formerly using for services such as Art Therapy, Positive Behaviour Practitioner, Speech Therapy, Occupational Therapy, Exercise/Physio etc?

Medical Needs

Please provide details of any diagnosis, allergies or special medical needs that can assist us in understanding how we can support them with our services.

Outcomes

Please let us know what outcomes they are looking for from Illawarra Therapies services, how can we best support the participant?

Other Comments or Useful Information

Please let us know anything else that can help us support them.

Supporting Documents

Please also provide the following documents (where relevant). You can upload the documents here or send us an email seperately.

Current NDIS Plan Goals
Safety Plan
Behaviour Support Plan
Other relevant Medical or Therapy Reports

To help us understand their needs and to prepare a support plan for the participant, we can use as much information as they're willing to share. If you have reports or plans that will help us prepare for communication, behaviour management and set clear goals for therapy outcomes, please upload the documents now, or email a copy of these through to info@illawarratherapies.com.au

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Allowed file types: .doc, .docx, .pdf, .png, .jpg Maximum file size 20MB