Referral Form – Ability&Ambition

1Participant Details

2Referral Details

3NDIS / Funding Details

4Support Needs

5Medical, Disability & Behavioural Information

6Key Contacts

7Referrer Details

8Consent & Submission

Please complete this form to refer a participant to Ability&Ambition. Required fields are marked with an asterisk (*). All information provided will be kept confidential.

Participant Details

Tell us about the person being referred.

Participant full name(Required)

Preferred name

Date of birth(Required)

Gender identity

Address(Required)

Street address, suburb, state and postcode.

Phone number

Email address

Is the participant under 18?(Required)

Yes

Parent/guardian name

Required if the participant is under 18.

Referral Details

Tell us about the referral itself.

Reason for referral(Required)

Service/s requested(Required)

Core supports (Assistance with Daily Living, Community Access)

Capacity building

Support coordination

Short term respite / STR

Youth mentoring

Other

Select all that apply.

Preferred location of support

Preferred days/times, if known

Is this referral urgent?(Required)

Yes

If urgent, please provide details

NDIS / Funding Details

This form supports both NDIS and non-NDIS referrals. Complete the sections that apply.

Funding type(Required)

NDIS

Self-funded/privately funded

DFFH/family services/organisation funded

Other

NDIS number, if applicable

Plan start date

Plan end date

Plan management type

Self-managed

Plan-managed

NDIA-managed

Plan manager company

Plan manager email

Plan manager phone

Support coordinator name

Support coordinator organisation

Support coordinator email

Support coordinator phone

Relevant funding category

Core

Capacity Building

Other

Select all that apply.

Hours or budget available, if known

Support Needs

Help us understand what the participant needs from us.

Description of support needs(Required)

Participant goals(Required)

Current informal/formal supports

Transport required?

Yes

Are there any known risks staff should be aware of?

Yes

If yes, please provide details

Medical, Disability & Behavioural Information

Provide information that helps us deliver safe, suitable support.

Primary disability(Required)

Secondary disabilities

Relevant health conditions

Medications we may need to be aware of

Allergies

Behavioural concerns

Is there a Behaviour Support Plan?

Yes

Unsure

Are there any current management plans?

Epilepsy

Asthma

Anaphylaxis

Diabetes

Mental health / safety plan

Other

Select all that apply.

Upload relevant plans/documents

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, xlsx, txt, rtf, Max. file size: 100 MB, Max. files: 10.

Please upload or email any relevant management plans, behaviour support plans, risk assessments, NDIS plans, or supporting documentation.

Key Contacts

Add the people we may need to contact about this referral. Use the Additional contacts list below for further contacts.

Contact type(Required)

Name(Required)

Relationship to participant(Required)

Phone(Required)

Address

Additional contacts

Contact type

Name

Relationship

Phone

Address

Add as many additional contacts as needed. For Contact type, use one of: Emergency contact, Parent/guardian, Plan nominee, Child representative, Advocate, Support coordinator, Other.

Referrer Details

Tell us about you, the person making this referral.

Referrer name(Required)

Organisation

Role/relationship to participant(Required)

Phone(Required)

Email(Required)

Are you the main contact for this referral?

Yes

Consent & Submission

Please confirm the following before submitting.

Consent(Required)

I confirm the information provided is accurate to the best of my knowledge.(Required)

Consent(Required)

I confirm the participant and/or their representative has consented to this referral being submitted.(Required)

Consent(Required)

I consent to Ability&Ambition contacting me regarding this referral.(Required)

Consent(Required)

I have read and acknowledge the Privacy Policy.(Required)

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