NDIS Referral

NDIS Referral Form

Complete this form to refer yourself or someone you support to Willow House Community Support Ltd.

Estimated time to complete: approximately 5 minutes.

Fields marked * are required. Where you do not know an answer, choose “Not sure” where available.

Who is making this referral?

Referrer phone number

Referrer email address

Who should Willow contact regarding this referral?

2. Participant Details

Participant full legal name

Participant phone number

Participant email address

Preferred contact method

3. Nominee / Authorised Representative

If there is no nominee, choose Not applicable.

Does the participant have a nominee or authorised representative?

Nominee / representative full name

Relationship to participant

Nominee / representative phone

Nominee / representative email

4. NDIS Plan & Funding

NDIS plan start date

How is the participant's NDIS funding managed?

What NDIS funding is currently available? Tick all that apply.

Approximate funding currently available for Psychosocial Recovery Coaching / relevant Capacity Building supports

Can you provide the relevant NDIS plan / funding information if Willow needs to verify the support category?

5. Support Coordinator Details

Does the participant currently have a Support Coordinator?

Support Coordinator full name

Support Coordinator phone

Support Coordinator email

6. Plan Manager & Invoicing Details

Invoicing details are required. If self-managed, provide the participant or nominee details used for invoices.

Who should Willow invoice?

Plan manager / invoice recipient name

Invoice / accounts email address

Plan manager / invoice contact phone

Plan manager participant / customer reference

Any invoicing instructions or purchase order requirements

7. Psychosocial Recovery Coaching Support

What would you like your Psychosocial Recovery Coach to help you with? Tick all that apply.

What would the participant like support with?

What would successful support look like for the participant?

8. Support Preferences

Preferred way to receive support (tick all that apply)

Preferred days / times

Approximate hours of support per week

Is transport support likely to be required?

Participant interests, activities or worker-matching preferences

Level of support required

9. Consent & Privacy

Privacy & confidentiality: Information provided to Willow House Community Support Ltd is kept private and confidential and is used for referral assessment, service delivery, administration and invoicing. Personal and sensitive information will only be shared with other services or third parties where the participant or authorised representative has consented, where sharing is reasonably necessary for the agreed purpose, or where disclosure is required or authorised by law.

Willow House handles personal information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs), and where applicable the Health Records Act 2001 (Vic) and its Health Privacy Principles.

Consent and declarations

The participant is aware this referral is being made The participant or authorised representative consents to Willow House contacting them I consent to Willow House using the information provided for referral assessment, service delivery, administration and invoicing I consent to relevant information being shared with other services where necessary and authorised for the participant’s support I confirm the information provided is accurate to the best of my knowledge I acknowledge the privacy and confidentiality information above