This form allows you to refer a Participant to us for services under the NDIS. Once submitted our Disability Services team will be in touch. If you have any queries, please call us on 1300 727 303
This form consists of both a referral form and a mandatory risk assessment questionnaire. The estimated time to complete it is 15 minutes.
All questions marked with an asterisk are compulsory
Participant First Name*
Participant Last Name*
Preferred Name
NDIS Participant Number*
Participant Date of Birth (DD/MM/YYYY)*
Primary Diagnosis
Participant’s Street Address*
Participant’s Suburb*
Participant’s Post Code*
Participant’s State*
Select State
NSW
QLD
VIC
WA
ACT
TAS
NT
SA
Participant’s Phone Number
Participant Email
As the Participant are you, or is the Participant, of Aboriginal and/or Torres Strait Islander origin?*
-- Select an option --
Aboriginal
Torres Strait Islander
Both of the above
Neither of the above
I would rather not say
Referring Party’s Name (typically you)*
Primary Relationship to Participant*
Select Your Role
I am the Participant
Advocate
Parent
Support Coordinator
Office of the Public Guardian
Other Family Member
Local Area Coordinator
House Manager
Other (please indicate below)
Other Relationship to Participant
Referring Party’s Phone Number*
Referring Party’s Email Address*
Other Relevant Contacts
Altius Group offers a range of assessments and therapies across QLD, NSW, ACT, VIC, NT, TAS, SA and WA (via In-Person and Video Telehealth) by the following Health Professionals:
Occupational Therapists
Exercise Physiologists
Psychologists
Physiotherapists
Therapy Assistants (Occupational Therapy)
Speech Pathology
Social Work
Please Note: Altius Group is able to provide these services to participants aged 7 years and older; We are not able to offer Positive Behaviour Support Services to any participant.
Plan Start Date
Plan End Date
Is the Referral Urgent?*
Select an option
Yes
No
If the referral is urgent, please explain why*
On what date is the completed service required?
First Type of Health Professional required*
Please select the first Health Professional you require
Occupational Therapy Services
Psychology Services
Workplace Assessment & modifications
Career Planning
Exercise Physiology Services
Physiotherapy Services
Speech Pathology
Social Worker Services
Service Required from First Professional (please use the scroll bar for more options)*
Select the primary service you require
Functional Capacity Assessment
Functional Capacity Living Needs Assessment
Functional Capacity Home and Living Assessment
Functional Capacity Assessment (Social Worker)
Initial Needs Assessment
Initial Assessment (Social Worker)
Brief Functional Capacity Assessment
Assistive Technology / Equipment Prescription
Complex Home Modifications
Minor Home Modifications
Capacity Building / Ongoing Therapy
Exercise Program (or hydrotherapy)
Mobility Assessment
Sensory Assessment (Occupational Therapist)
Swallowing Assessment (Speech Pathologist)
Communication Assessment (Speech Pathologist)
Other
Funded Hours Available for this Service*
Second Type of Health Professional required (optional)
Please select the second Health Professional you require, if any
Occupational Therapy Services
Psychology Services
Workplace Assessment & Modifications
Career Planning
Exercise Physiology Services
Physiotherapy Services
Speech Pathology
Social Worker Services
Service Required from Second Professional (please use the scroll bar for more options)
Select the primary service you require
Functional Capacity Assessment
Functional Capacity Living Needs Assessment
Functional Capacity Home and Living Assessment
Functional Capacity Assessment (Social Worker)
Initial Needs Assessment
Initial Assessment (Social Worker)
Brief Functional Capacity Assessment
Assistive Technology / Equipment Prescription
Complex Home Modifications
Minor Home Modifications
Capacity Building / Ongoing Therapy
Exercise Program (or hydrotherapy)
Mobility Assessment
Sensory Assessment (Occupational Therapist)
Swallowing Assessment (Speech Pathologist)
Communication Assessment (Speech Pathologist)
Other
Funded Hours Available for this Service
What Other services do you require?
Is Telehealth (via video) an option for the Participant?*
-- Select an option --
Yes, Telehealth is an option
No, Telehealth is not an option
Do you have a preference for the gender of your consultant?*
-- Select an option --
Yes, I prefer a female consultant
Yes, I prefer a male consultant
No, I do not have a preference, or my preference is not listed
Is the Service Agreement to be sent to the Participant or their Representative for signature?*
-- Select an option --
The Participant AND Support Coordinator
Their Representative AND Support Coordinator
ONLY to Support Coordinator
Current Funding Management*
-- Select an option --
Self-Managed
Agency Managed
Plan Manager Managed
Email address for invoicing
Is Third Party approval required?*
e.g., OPG or Child Services – please select
No
Office of the Public Guardian
Child Services
Email address for the Third Party for approval
What are you hoping to achieve from the referral?
Do you have any additional comments?
Please provide the name of your preferred Altius Group NDIS consultant, if known
Upload Goals Document (optional)
If possible, please upload a copy of the Participant’s Goals document.
This document may be required to fulfill service delivery, so if not provided here we may request it following your referral.
How did you hear about us?
How did you hear about us?
Google
LinkedIn
Facebook
Email
Word of Mouth
Referral
Other
Would you like to know more about our Disability Employment Service (DES)?
-- Select an option --
Yes, please send me details
No
MANDATORY RISK ASSESSMENT QUESTIONNAIRE
Are there any communication supports in place or required?*
-- Select an option --
Yes
No
Please specify communication supports*
Is an interpreter required?*
-- Select an option --
Yes
No
Please specify interpreter requirements*
Does the participant live alone?*
-- Select an option --
Yes
No
Does the participant live in a remote area?*
-- Select an option --
Yes
No
Are the any concerns around the participants home environment we should be aware of?*
-- Select an option --
Yes
No
Please specify the concerns*
Does the participant have any behaviours of concern?*
-- Select an option --
Yes
No
What are the behaviours of concern?*
Can the participant potentially become agitated or aggressive?*
-- Select an option --
Yes
No
Please specify*
What are the known triggers causing the behaviours of concern?*
Is there a current positive behaviour plan in place?*
-- Select an option --
Yes
No
Please provide a copy of the behaviour plan by uploading it here (required)*
Will an authorised person, guardian, support worker or other nominee be present during assessments and face to face interactions with the participant?*
-- Select an option --
Yes
No
Please specify details of attendance*
Has the participant been convicted of a criminal offence in the past?*
-- Select an option --
Yes
No
Are there any legal orders currently in place?*
-- Select an option --
Yes
No
Are there any other considerations we should be aware of?*
Easily fatigued
Needs assessment away from home environment
Other house members have behaviours of concern
Weapons present
Animals present
Other
None
Select the options that apply (you may select more than one)
Does the participant have a gender preference? If so, please indicate it here.
Are there any cultural considerations to be aware of?
Submit
Make a Referral
