AJH Intake Form - Existing Participant
Referral Form
Participant's First Name
Participant's Last Name
Have any of the following participant details changed? Please select all that apply
Address
Contact Details
Plan dates
Contacts
No changes
Participant's Address
Address Line 1
Address Line 2
City
State
Please select...
QLD
NSW
VIC
SA
WA
ACT
NT
TAS
Postcode
Participant's Contact Details
Email
Mobile Phone Number
Home Phone Number
Preferred Method of Contact
Please select...
Email
Mobile Phone
Home Phone
Nominee (See below)
Guardian (See below)
NDIS Plan Dates
Start Date
End Date
Participant's Contacts
Do you [the participant] have any of the following? (Please select all that apply)
Formal Guardian
Informal Guardian
NDIS Plan Nominee
Not Applicable
Formal Guardian Contact Details
First Name
Last Name
Phone
Email
Informal Guardian Contact Details
First Name
Last Name
Phone
Email
Plan Nominee Contact Details
First Name
Last Name
Email
Phone
Referrer Details
First Name
Last Name
Phone
Email
Relationship to Participant
Service/s Required (Select all that apply for this referral)
Drug and Alcohol Counseling
Assessment and Report
CB - Improved Relationships (Behaviour Support)
Specialist Support Coordination
Allied Health / Therapy Assistant (requires some hours in the budget for supervision by an Allied Health Practitioner)
Therapeutic Intervention (by a psychologist, OT or social worker)
Support Coordination (Level 2)
STAR Program - Sexuality: Talking About Relationships Program
SPORT Program - Social Problem Solving Program
Occupational Therapy
Psychosocial Recovery Coaching
Please note with regards to Therapeutic Intervention - Our practitioners work remotely across SE QLD. Because of this we may not be able to offer face-to-face therapy. If we can't offer face-to-face intervention, is the participant willing to have ongoing therapeutic intervention via telehealth (e.g., Zoom)?
Yes
No
Please attach a copy of your NDIS Plan (Required for Support Coordination referrals but it's ok if you don't have it handy right now - you can send it to us by email intake@ajh.org.au later)
Please attach a copy of your NDIS Plan goals. (If you'd like to attach the whole plan, that's ok too). If you don't have it handy right now, you can send it to us by email intake@ajh.org.au later.
Budget that the work will be paid from
Core
Capacity Building - Improved Daily Living
Capacity Building - Improved Relationships
Capacity Building - Support Coordination
Capacity Building - Improved Health and Wellbeing
Early Childhood Early Intervention
Select all that apply
Referral Information
Proposed amount (core)
$
Proposed amount (CB-Support Coordination)
$
Proposed amount (CB-IR Specialist Behaviour Support)
$
Proposed amount (CB-IR Plan writing and training)
$
Proposed amount (CB-IDL)
$
Proposed amount (ECEI)
$
Proposed amount (CB-IHW)
$
Finance Information
How is the Participant's NDIS Budget managed?
Agency (NDIA)
Self Managed
Plan Managed
Plan Manager Details
Plan Manager Name
Email for Invoicing
Invoicing Details
Name
Email for Invoicing
Date work is required to be completed by (if applicable)
Date
Please provide a date if the work being requested is for review purposes
Service Agreement
How would you like to receive the service agreement?
Receive the Service Agreement by email to sign electronically
Sign the Service Agreement with the Practitioner at the first meeting
Please provide name and contact email
Would you like to receive a PDF version of the Service Agreement by email for review prior to the first appointment?
Yes
No
Who should the copy of the Service Agreement be sent to for review?
(Select all that apply and please make sure email contact has previous been provided for the nominated party or changed above if applicable)
Participant
Plan Nominee
Informal Guardian
Formal Guardian
Support Coordinator
Other
Please provide name and contact email
Reason for referral
Please provide as much information as possible including hoped for outcomes of referral, linked participant goals for the referral, relevant diagnoses, dates work is required to commence and/or be completed by.
Contact Information
