Care to Support
0414933555
info@caretosupport.com.au
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Accommodation/ Tenancy
Assist with travel transport
Assist-Life Stage, Transition
Assistance with Household Tasks
Assistance with Personal activities
Community Nursing Care
Development of life skills
Group based activities
Innovative community participation
Supported Independent Living (SIL)
Respite Care
Emergency Accommodation/ Transition
Resources
Contact Us
About Us
Referral
Contact Us
Menu
Home
Services
Accommodation/ Tenancy
Assist with travel transport
Assist-Life Stage, Transition
Assistance with Household Tasks
Assistance with Personal activities
Community Nursing Care
Development of life skills
Group based activities
Innovative community participation
Supported Independent Living (SIL)
Respite Care
Emergency Accommodation/ Transition
Resources
Contact Us
About Us
Referral
Referral Form
Referral Form
Please complete this form when making a referral to Kangaroo Disability Services. You can save the form as a draft at the bottom of this page.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Participant First Name
*
Preferred Name (if different from legal first name)
Participant Last Name
*
Participant Date of Birth
*
Date
Participant Gender*
*
Please Select
Male
Female
Other
Prefer Not to Say
Participant Email
example@example.com
Does the participant have a phone number?
*
Please Select
Yes
No
Participant's Preferred Method of Communication
*
Please Select
Telephone
Email
Text / SMS
All / Any
NDIS Number
*
NDIS Plan Start Date
*
Date
NDIS Plan End Date
*
Date
Current Living Arrangements
*
Please Select
With others
Alone
With family
Hospital
Participant Physical Address
*
Street Address
Street Address Line 2
Street Address Line 2
City
City
State / Province
State / Province
Postal / Zip Code
Postal / Zip Code
Culture and Language
Please tell us about the participant's culture and language requirements.
Participant Country of Birth
*
Participant First Language
*
Participant Second Language (if applicable)
Does the participant require a translator?
*
Please Select
Yes
No
Does the participant have any culture, diversity, values and beliefs of which we should be aware?
*
Please Select
Yes
No
Disabilities
Please select Yes or No for each possible disability - there is room for further diagnosis and medical detail after this.
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Autism
Please Select
Yes
No
Brain Injury
Please Select
Please Select
Yes
No
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Cerebral Palsy
Please Select
Yes
No
Developmental Delay
Please Select
Please Select
Yes
No
Layout (copy) (copy)
Down Syndrome
Please Select
Yes
No
Epilepsy
Please Select
Please Select
Yes
No
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Global Developmental Delay
Please Select
Yes
No
Hearing Impairment
Please Select
Please Select
Yes
No
Layout (copy) (copy) (copy)
Intellectual Disability
Please Select
Yes
No
Multiple Sclerosis
Please Select
Please Select
Yes
No
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Psychosocial Disability
Please Select
Yes
No
Spinal Cord Injury
Please Select
Please Select
Yes
No
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Stroke
Please Select
Yes
No
Visual Impairment
Please Select
Please Select
Yes
No
Diagnosis / Medical Conditions
Please enter any other relevant diagnosis, disability, or medical information.
Tell us about the participant's diagnosis and medical conditions
*
Does the participant have any regular allied health appointments?
Allergies
Please select Yes or No for each possible allergy - there is room for further allergy detail after this.
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Drug Allergy
Please Select
Yes
No
Food Allergy
Please Select
Please Select
Yes
No
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Insect Allergy
Please Select
Yes
No
Latex Allergy
Please Select
Please Select
Yes
No
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Mould Allergy
Please Select
Yes
No
Pet Allergy
Please Select
Please Select
Yes
No
Pollen Allergy
Please Select
Yes
No
No Tell us more about your allergies (if applicable)
Behaviour Support Plan
Does the Participant have a Behaviour Support Plan?
*
Please Select
Yes
No
Is the Participant Physically Abusive?
*
Please Select
Yes
No
Reports
Please upload any relevant Allied Health reports such as OT, Speech Therapy, Psychologist etc
Allied Health Reports - Upload
Browse File
Drag and drop files here
Choose a file
Ratios, Gender, and Age Preferences
Preferred Gender of Support Workers
*
Please select
Male (only)
Female (only)
Don't Mind
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Minimum Age of Support Worker
*
Enter your preference
Maximum Age of Support Worker
*
Enter your preference
Support Requirements
Please let us know what supports are required for each category. There is a separate section for shift start and end times after this.
Personal Care
*
Please Select
Yes
No
Does the participant require support with Personal Care?
Mobility
*
Please Select
Yes
No
Does the participant require support with Manual Handling?
Transfers
*
Please Select
Yes
No
Does the participant require support with Transfer?
Domestic Assistance
*
Please Select
Yes
No
Does the participant require support with Domestic Assistance?
Community Participation
*
Please Select
Yes
No
Does the participant require support with Community Participation?
Mealtime Management
*
Please Select
Yes
No
Does the participant require support with Mealtime Management?
Communication
*
Please Select
Yes
No
Does the participant require support with Communication?
Medication Management
*
Please Select
Not Required
Promoting
Assisting
Administering
Unsure
Informal Supports
*
If informal supports via friends, family, neighbours are in place, please include details here.
Services Required
Tick all that apply
NDIS - Services Required
Supported Independent Living (SIL)
Short-Term Accommodation (STA)
Respite
Community Participation
In-Home Care
Day Options (Cooking and Baking class, Art and Crafts Day, Community Outing Day, Disco and Karaoke)
Goals & Interests
Now please let us know about the participant's goals.
How Do You Want To Tell About Goals?
Please Select
Refer to NDIS Plan for Goals
Tell You More
Hobbies and Interests
*
Power of Attorney
A Power of Attorney is a legal document that gives a person, or trustee organisation the legal authority to act for you to manage your assets and make financial and legal decisions on your behalf.
Does Power of Attorney Apply to the Client?
*
Please Select
Yes - Enduring the Power of Attorney
Yes - General the Power of Attorney
No
Nominee
Guardians are not nominees under the NDIS and there is no automatic process for guardians to be made nominees (although sometimes the Guardian and Nominee end up being the person or organisation)
Does the Participant have a Nominee?
Please Select
Yes - Plan Nominee and Correspondence Nominee (combined)
Yes - Plan Nominee (only)
Yes - Correspondence Nominee (only)
No
Guardianship
Guardianship allows the Guardian to make decisions about your health and daily care in the event you can't make those decisions. If you have a Guardian, they make decisions about matters such as where you live and the services you might receive, healthcare, medical and dental treatment.
Does Guardianship Apply to the Participant?
*
Please Select
Yes - Enduring Guardian
Yes - Public Guardian
No
Support Coordinator
Does the participant have a Support Coordinator?
Please Select
Yes
No
Plan Manager
Is the participant Plan Managed?
*
Please Select
Yes
No - Agency NDIA Managed
No - Self Managed
For KDS services that will be billed.
General Practitioner
GP - Organisation Name
GP - First Name
GP - Last Name
GP - Email
example@example.com
GP - Phone Number
Please enter a valid phone number.
GP - Address
Street Address
Street Address Line 2
Street Address Line 2
City
City
State / Province
State / Province
Postal / Zip Code
Postal / Zip Code
Who shall we speak to about this referral?
Referring Full Name
*
First Name
Last Name
Last Name
Referring - Email
*
example@example.com
Referring - Phone Number
Please enter a valid phone number.
Final Important Notes
Are there any further important notes that need to be communicated?
Submit
