Make a Referral Home Make a Referral Make a ReferralNDIS NumberFirst NameLast NameDate / TimeArea CodePhone NumberEmailAddressStreet AddressCityStatePostal / Zip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweLanguage English Other Languages Interpreter Required Auslan TTL CALD Torres Strait IslanderInterpreter Required Yes NoName of the guardianLast Name of the guardianRelationship with the participantPhone NumberArea CodeEmailNDIS Plan Start DateNDIS Plan End DatePlan Manager NameLast NamePlan Manager Email AddressDoes the Participant live alone Yes NoIs the participant supported by only one worker? Yes NoFull name of the Support CoordintorLast NameSupport Coordinator's EmailArea CodeName of Emergency ContactLast NameCountry CodeArea CodePhone NumberPreviousNextShort - Term GoalMedium - Term GoalLong - Term GoalPreviousNextAllergies/Alerts: Primary DisabilitySecondary Health/Medical Conditions:Is the client at risk of choking, seizures or anaphylaxis? Yes NoIs assist with medication administration required? Yes NoDoes Client suffer from irritants, phobias or any other specific condition? Yes NoDo you give consent to share this form with your support network, other providers, and relevant government agencies? Yes NoDescribe the support needs required:PreviousNextIs this home easy to locate? Yes NoIs onsite/street parking available for support worker’s car? Yes NoAre any gates or doorways difficult to use or access? Yes NoAt night, is the house entrance hard to find? Yes NoAre there any slip, trip or falling hazards outside the home? Yes NoIs the home wheelchair accessible? Yes NoAre there any slip, trip or falling hazards inside the home? Yes NoWill the support worker be required to use any electric appliances? Yes NoIn case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting pointsIs there anything else you would like to share about the home?NOTE:It is the participant’s responsibility to ensure certain safety requirements. 1. Electrical appliances and power cords are in good working order.2. Power cords are attached to power boards and power sockets, and not double adapters.3. The house is fitted with a working smoke alarm.4. The fuse box is fitted with a safety switch.5. Support workers will not be exposed to cigarette smoke in the homePreviousNextAre there any places, situations or specific irritants that should be avoided?Is there a risk that participant may abscond? Yes NoPlease provide details on how to manage this risk. Describe in detail if there is any way to avoid.If something goes wrong in the community, are there any specific emergency instructions for the support worker?PreviousNextWhat type of transport participant will use? Please tick the relevant Public Transport Using the participant's car (with the support worker driving) Using the support worker's car OtherAre there any specific risks associated with transport?If something goes wrong, are there any transport-specific emergency instructions for the support worker?Do you give consent for the support worker to proactively support you in attending medical, and allied health services? Yes NoGlobal Support Network will take reasonable efforts to work with the participant in selecting the preferred support workerDate / Time Previous
