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Donations
Referrals
Community Care Foundation
Referrals
Participant Information
First Name
*
Last Name
D.O.B
*
Region
*
Hervey Bay
Maryborough
Other
Gender
*
Female
Male
Undisclosed
Other Region
If your region is not listed please specify it here.
Type of Funding
*
NDIS
DVA
NIISQ
Private
Other
Referred By
*
NDIS LAC
Support Coordinator
Guardian/ NDIS Nominee
Self
Other
Funding Source
*
If your funding source differs to those listed, please fill it in here.
Other Referral
Who referred you to LifeChoice?
Referrers first name
*
Referrers last name
Contact number of referrer
*
Referrer email address
Please list any known disability diagnoses
*
Does the participant have behaviours of concern?
*
No
Yes
Supports required by Community Care Foundation
Supports required by Community Care Foundation?
*
Support Services
Support Coordination
Participant Support
Type of Support required
*
SIL - Supported independent Living
ADL – Assistance with Daily Living
Community Access/ Social Participation
Employment Support
(Non-SIL) Approx. hours per week support required
*
5 or under
10 or under
15 or under
20 or under
30 or over
(Non-SIL) Preferred Times for support
*
6:00AM - 9:00AM
9:00AM - 12:00PM
12:00PM - 3:00PM
3:00PM - 6:00PM
6:00PM - 9:00PM
After 9PM
Any specific support staffing preferences/ requirements, or comments?
Allied Health
Type of clinician required
*
Occupational Therapy
Physiotherapy/ Exercise Physiotherapy
Speech Therapist
Psychology/ Counselling/ Social Work
Type of support required:
*
Functional Assessment
Assistive Technology Assessment
Home Modifications
Ongoing Therapy
How soon do you require supports to commence?
*
Urgent
Within 1 month
Within 2-3 months
Over 3 months
Any specific clinical staffing preferences/ requirements, or comments?
Support Coordination
What is your current Support Coordination situation?
*
No current Support Coordinator – looking for first time
No current Support Coordinator – have left past Support Coordinator
Have current Support Coordinator – wanting to transfer to Life Choice as new provider
Any specific support coordinator preferences/ requirements, or comments?
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