Referral for Civic Clinical Supports and Support Coordination

Applicant Information

First Name *

Last Name *

Street Address *

Suburb *

Postcode

Disability

Date of Birth *

Preferred communication method

Phone number

email address

Aboriginal and/or Torres Strait Islander

Yes No Prefer not to say

Preferred Language

Is there a legal guardian in place?

Yes No

Details

Funding Source *

NDISiCareAged Care (HCP)Fee for Service

My Aged Care (MAC) number

Comments

Person completing the form

Same as above *

Yes No

Full Name *

Relationship to applicant *

Phone Number *

email address

Are you the NDIS plan Nominee? *

Yes No

NDIS Information

NDIS number *

Plan start date *

Plan end date *

Support coordinator name *

Organisation name

Support Coordinator email *

Support Coordinator phone Number

Plan Manager email address *

Plan Manager Organisation

Invoice email if self managed *

Plan Nominee full name *

Nominee phone number *

Plan Nominee address

Plan Nominee email

Emergency Contact

As above / same as nominee

Full Name

Relationship to applicant

Phone number

email address

Address

Further information

Who should we contact for more information? *

Applicant Plan nominee Emergency contact Support Coordinator

To whom shall we send the Service Agreement? *

Service Required

Nursing Supports

YesNo

Category *

CoreCapacity Building

Funded hours

Details of support *

Behaviour Support

YesNo

Line Items

11_023_0110_7_3 11_022_0110_7_315_056_0128_1_3 - report writing

Funded Hours

Details

Clinical Psychology

Yes No

Line item

15_054_0128_1_301_701_0128_1_3

Funded Hours

Details *

Counselling

YesNo

Line Item

15_043_0128_1_3

Funded Hours

Details

Support Coordination

YesNo

Level *

2: 07_002_0106_8_33: 07_004_0132_8_3

Funded Hours

NDIS Goals

Goal

Please upload completed Consent form, Screen shot of the related funding section in the NDIS plan, or any other relevant documents

Browse

i.e. NDIS plan, OT report, Behaviour Support Plan

Home visit safety checklist

Type of residence *

Other details

Specific instructions

Is the property in a known unsafe area? *

YesNo

Is there parking? *

YesNo

Instructions/details

Is there mobile phone coverage? *

YesNo

Are there any weapons on site? *

Yes No

Safety details *

Are there any pets on site? *

Yes No

Details

Are there any hazards you are aware of that would make access to this property difficult? (e.g. steps, house is hidden from the street, seasonal bushfire risk) *

YesNo

Details

Does the participant or other people in the home have a history of actual or threatened violence or aggressive behaviour? *

Yes No

Details

Does the participant have a positive behaviour support plan? *

Yes No

Please upload a copy to this form if consent is given

Is it likely any people within the home will be smoking or drinking alcohol during our visit? *

YesNo

Details

Is there known substance abuse amongst people who may be present? *

YesNo

Details

Are you aware of any occupant having an infectious disease? (e.g. COVID-19, chicken pox, shingles, gastro, MRSA) *

YesNo

Details

Any other information you would like to add

Consent and declaration

You or your authorised representative* must provide consent for the information provided in the Civic Services application (and requested assessments and reports) to be used in the following ways:

To create a file (electronic and/or paper).
For assessment purposes.
To be shared with clinicians/support coordinators and their managers for the purposes of providing appropriate support to the applicant.
For statistical reporting (information is de-identified).

*Your representative could be a primary carer, family member, advocate or an appointed guardian. A paid worker such as a case manager or support worker cannot be your representative.

WRITTEN CONSENT & DECLARATION

I have been informed and consent to the use of information in the application for the Civic Services I am applying for. I understand this information may be used to create a file (electronic or paper). I also understand this consent allows for information in this application to be used for statistical reporting.

I declare I have provided all information relevant to my application for Civic Services and the information given on this form is true and correct to the best of my knowledge.

Applicant representative

Full Name *

Date *

Signature

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Relationship to applicant

VERBAL CONSENT

Only to be used where it is not possible to obtain written consent.

I have discussed the purpose and disclosure of the information with the applicant or their representative and I am satisfied they understand how the information will be used and they have provided informed consent to the submission of this application for support.

Verbal consent provided by

Date

Full name

Relationship to applicant

Signature

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