Referral Form.Accepting new referrals for June 2024 . Before you fill out this form, please remember that we cater to Brisbane, Logan, Ipswich, Gold Coast, Redland and Moreton Bay regions. We are primarily a home-visit based service in order to cater to a wide range of disabilities. Who is filling out this form? * CLIENT/PARTICIPANT SUPPORT COORDINATOR PARENT/NOMINEE Name of the person filling out this form * First Name Last Name Client/Participant's name * First Name Last Name Client/Participant's date of birth (we only see adults over the age of 18 years) * Does the client/participant identify as Aboriginal or Torres Strait Islander? * No Aboriginal and Torres Strait Islander Aboriginal Torres Strait Islander Does the client/participant require a language interpreter? * YES NO NA Does the client/participant require an AUSLAN interpreter? * YES NO NA For non-NDIS clients: Please tell us your concerns in brief. For NDIS participants: Please indicate the access diagnosis. Preferred email to coordinate further communication regarding this referral. * Preferred phone number to contact regarding this referral. * (###) ### #### Suburb or postcode for the home-visit appointment. * Preferred day or times for appointments. There could be a waiting period of 1 or 2 months for appointments. Please indicate if this is suitable. * YES NO Participant's NDIS number if already funded by the NDIS. NDIS funding type * PLAN-MANAGED SELF-MANAGED AGENCY-MANAGED I AM NOT WITH THE NDIS Plan start date Please enter in month/day/year format MM DD YYYY Plan end date Please enter in month/day/year format MM DD YYYY Type of assessment needed * DIAGNOSIS FUNCTIONAL CAPACITY ASSESSMENT COGNITIVE/INTELLECTUAL ASSESSMENT HOME & LIVING NEEDS ASSESSMENT ASSESSMENT TO APPLY FOR NDIS OR OTHER FORMAL FUNDING/DISABILITY SCHEME Please send me a quote for the service. * YES Current risks and alerts such e.g. aggression, seizures, current family violence situation, forensic orders, etc. If none, say "no". * Any previously known difficulties engaging with allied health professionals. * YES NO UNSURE Any other helpful information regarding the referral, e.g. background, past diagnosis, assessments done, specific needs. Thank you! Psychologist Tulsi Achia will contact you in 24-48 hours to clarify your assessment needs and guide you through the next steps.