Participant Risk Assessment

Participant Details

First Name *
Last Name *
Date of Birth *
Address *
Suburb *
State *
Post code *
Phone
Email
What is your preferred contact method? *
If you prefer us to contact your representative please complete their contact details below.

Authorised Representative

First Name
Last Name
Phone
Email

NDIS Details

NDIS Number *
NDIS Plan Start Date *
NDIS Plan End Date *
Please indicate if you would like to opt out of the NDIS Audit process (optional)

Support Coordinator Details

First Name
Last Name
Phone
Email

Financial Contact Details

How is the Participant's plan managed? *
Company
Contact Name
Billing Address
Suburb
State
Postcode
Contact Email (where should invoices be sent?) *
Line Item Category for Required Supports *

Participant Background Details

What are the Participant's NDIS Goals? *
About the Participant *
Please list any Support Worker preferences
What is the Participant's primary diagnosis? *
Does the Participant have any additional diagnoses?
Participant's Gender
Participant's Pronouns
Does the Participant identify as LGBTIQA+?
If yes, please specify
Does the Participant identify as Aboriginal / Torres Strait Islander? (Select all that apply)
What is the Participant's preferred language?
Please specify the Participant's preferred language
How does the Participant communicate? (select all that apply) *

Participant Health & Safety Details

Does the Participant take regular medication? *
If yes, please list the medications
Does the Participant have a BSP? *
Will these supports require the implementation of restrictive practices? *
If yes, please list below

Schedule of Support

Please select which days and times regular support is required

Monday
Start
Finish
Tuesday
Start
Finish
Wednesday
Start
Finish
Thursday
Start
Finish
Friday
Start
Finish
Saturday
Start
Finish
Sunday
Start
Finish
Are there any regular support requirements, please include any regular appointments or errands?

Supporting Documents

Please upload any documents or information
Maximum file size: 10 MB
This may include the Participant's NDIS Plan, their BSP and any other relevant or supporting documentation.

If you would prefer to complete the form offline please download the form using the link below and return the completed form to us by email at home@ands.com.au

Download NDIS Referral Form