Participant Name *

First

Last

Date of birth *

DD/MM/YYY

NDIS Number *

Phone Number *

Email *

Address

Decision maker / parent / guardian contact details

Add if relevant.

Emergency Contact Name

Emergency Contact Phone

NDIS Support Coordinator Name

NDIS Support Coordinator Phone

NDIS Plan start date

NDIS Plan end date

Frequency of sessions required

Allocated funds

Fund Management Type:

Plan Managed
Self-Managed
Plan Nominee

Please note we are unable to provide services for NDIA Managed participants.

Plan Manager invoice email

Funding Support Category

Appointment reminders

SMS
Email
SMS & email

Relationship status

Occupation

Court Orders

Psychiatric medication

Reason for the counselling:

This information will help your therapist better understand your needs (check all relevant boxes). *Please provide your practitioner with a copy of the participant’s goals at the end of this form.

Please provide the following information about your participant so we can better understand and support their needs.

What is the participant’s current disability/diagnosis? (required) *

Why is the client seeking psychological services at this point in time? (required) *

Please highlight relevant history

Any requirements we should be aware of, for example: male or female therapist, specific days/time for appointments, that may impact allocating a therapist?

Are there any behaviours of concern? (please forward a copy of the BSP)

Any subjects/events/objects that are triggering for this person?

Forensic involvement (current/historic)

Participant’s Goals

Type your full name below to agree to the disclosure of the details in this form to Mind@Work Psychology for the purposes of psychological therapy.

OR if you are a support cordinator type your name and organisation below to agree that you have gained the written or verbal consent of this participant to disclose the details in this form to Mind@Work Psychology for the purposes of psychological therapy.

NDIS Referral form

NDIS Referral form