Raya Healthcare Referral/Intake Form

Referral Date *

Person Completing Form *

Section 1: General Information

Participant/Client Details

Full Name

Pronoun/Gender

Preferred Name

Date of Birth

Address

Street address

City

State

Postcode

Other Address

YesNo

If their current above address is different to their known address (eg. currently in hospital, what is their address when they are discharged). Or different to NDIS Plan.

Known Address

Street address

City

State

Postcode

Home Phone

Mobile Number

Email Address

Preferred Contact Method

Mobile PhoneHome PhoneEmailAlternative Contact

Languages Spoken

Aboriginal/Torres Strait Islander

AboriginalTorres Strait IslanderBothNeither

Supports Required

Supports RequiredPlease tick all that apply

Next of Kin/Alternative Contact

Full Name

Pronoun

Preferred Name

Relationship

Plan NomineeChild Representative Power of Attorney

Address

Street address

City

State

Postcode

Home Phone

Mobile Number

Email Address

Preferred Contact Method

Mobile PhoneHome PhoneEmail

Referrer Details

Name

Organisation

Contact Number

Contact Email

Other

Section 2: NDIS Participant Information

NDIS Details

Participant NDIS Number

Plan Start Date

Plan End Date

Primary Disability/ies

Secondary Disability/iesAre there any other disabilities that are known?

Fund Management

How is your Plan Managed? *

Plan ManagedSelf-ManagedNDIA (Agency) ManagedOther

If unsure, I can find out by looking at your NDIS Plan or you can speak to your LAC (Local Area Coordinator) and find out. Their information is on your NDIS Plan. Without this information we are unable to start services,

Other

Plan Manager Name/Company NameIf you are unsure about who your Plan Manager is, you can go back to your LAC (Local Area Coordinator) and ask them. Without this, we are unable to create a Service Agreement and therefore, can't start services.

Plan Manager Contact Number

Self-Manager Name:Person who is doing the Self-Managed funding.

Where to Send Invoices

Section 3: Further Information

Legal OrdersAre there any legal orders, current or past, such as restraining orders, AVOs - for or against, Power of Attorney, Advanced Care Plan (End of Life Care Plan), etc. (Why? In case something comes up, so we can assist/inform parties concerned of the relevancy.) It doesn't go anyway, just put on our files for reference, if needed.

Any Other Relevant Information

Section 4: Support Worker Requirements

Gender of Support Worker

FemaleMaleEither/Doesn't Matter

PetsDoes the Participant have any pets at their house, if yes, what types of pets, etc.

Please choose your Days and Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Section 5: Short and Medium Term Accommodation

Reason for STA/MTA? Is it a holiday? For an event/function? While in-between housing? Respite?

Dates for STA/MTA?If known. Otherwise a general month is preferred

Ideal Location?Where is the participant wanting their STA to be?

Any special requests when looking at accommodation? Pet friendly? How many rooms? Single story? Double story? Steps?

Activities Intending to Participate inEvents, activities, sight-seeing?

Support Worker Information

Do you need a Support Worker from us?Do you have a Support Worker from another company?Do not need a Support Worker at all?

Gender of Support Worker

FemaleMaleEither/Doesn't Matter

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