NDIS Referral Form - Northern District Community Health

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Service Provider to supply service/s: *

Agency requesting the service/s: *

Agency contact details: *

Date of request: *

Participant Name: *

First

Last

Participant address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Participant contact details: *

Participant NDIS#: *

Plan dates:

From date: *

To date: *

Gender identity: *

Date of birth: *

Diagnosis: *

Hours available for the request: *

Plan Manager (if not NDIA): *

Phone: *

Plan Manager Address: *

Email: *

Participant Parent/Carer: *

Phone: *

Please select the following that relates to the participant:

NDIS Support Name & Support Item Reference Number

Description of Support & Support Item Reference Number

Support Price Per Unit *

Option 1

Level 2: Coordination of Supports 07_002_0106_8_3

Further qualifications/experience required to strengthen a participant’s ability to design and then build their supports with an emphasis on linking the broader systems of support across a complex service delivery environment. Coordination of Supports is to focus on supporting participants to direct their lives, not just their services. This may include resolving points of crisis, and developing resilience in the participant's network.

$100.14 an hour

Option 2

Individual Assessment Therapy and/or Training (Includes Assistive Technology) 15_617_0128_1_3

Assessment, recommendation, therapy, and/or training, including Assistive Technology.
- Occupational Therapy

$193.99 an hour

Option 3

Occupational Therapy | Speech Pathology - Under 7 years of age | 15_005_0118_1_3

Early Childhood Supports - Early Childhood Professional
• Developmental Educator
• Early Childhood Teacher or Educator
• Occupational Therapist
• Social Worker
• Speech Pathologist
• Other Professional

$193.99 an hour

Option 4

Individual Assessment Therapy and/or Training (Includes Assistive Technology) 15_619_0128_1_3

Assessment, recommendation, therapy, and/or training, including Assistive Technology.
- Podiatry

$193.99 an hour

Option 5

Assessment, Recommendation, Therapy or Training (including Assistive Technology) - Physiotherapy 15_055_0128_1_3

• Provision to a participant of Assessment, Recommendation, Therapy, or Training (including in assistive technology) supports.
• The support must be delivered by a Physiotherapist.

$193.99 an hour

Option 6

Physiotherapy - Under 7 years of age 15_003_0118_1_3

Early Childhood Supports - Physiotherapist

$193.99 an hour

of attach Participant's

Option 7

Dietitian Consultation And Diet Plan Development 12_025_0128_3_3

Individual advice to a participant on managing diet for health and well-being due to the impact of their disability.

$193.99 an hour

Option 8

Individual Assessment And Support By A Nurse 01_618_0114_1_1

Provision of care, training and supervision of a delegated worker to respond to the complex care needs of a participant where that care is not the usual responsibility of the health system.

$151.03 an hour

Option 9

Assessment Recommendation Therapy or Training – Psychologist 15_054_0128_1_3

Assessment Recommendation Therapy or Training – Psychologist

$214.41 an hour

Option 10

Assessment Recommendation Therapy or Training - Exercise Physiologist 15_200_0126_1_3

Assessment Recommendation Therapy or Training - Exercise Physiologist

$166.99 an hour

* All prices correct as of 7th February 2024. Please contact us to confirm any price changes.

NDCH Contact

Phone: (03) 5451 0200

Email: [email protected]

Plan Goals: *

Additional Comments: (e.g. Participant's daily life, supports engaged, living arrangements) *

Name of person filling in this form: *

First

Last

Please attach your NDIS plan and/or any other supporting documents

Click or drag files to this area to upload. You can upload up to 5 files.

If not the Participant, role of person filling in form: *

I declare that this Referral / Service Request has been discussed with and agreed to by the participant. *

I declare that this Referral / Service Request has been discussed with and agreed to by the participant.