Referral for Clinical Supports, Support Coordination and Biala Allied Health Services v3.0

PLEASE READ BEFORE COMPLETING THE FORM

Important information for applicants/support network

Please complete all sections of this form. It is essential that ALL information is as detailed and accurate as possible to fully assess the support requirements of the applicant.
The application should be accompanied by documentation that supports statements about the applicant’s support needs, for example behaviour support plans, health care plans and personal care protocols.
A member of the Customer Experience Team may contact the person nominated on the form if further information is required to support the application.
Insufficient or inaccurate information may impact on the offer of services, including withdrawal of offers made on the basis of inaccurate information provided in the application form.
Applicants will be contacted by our Customer Experience Team to advise you of the progress of your application and to advise of any necessity to further assess the suitability of the applicant.
Contact the Customer Experience Team (1300 692 484) if you have any questions regarding this form.

Applicant Information

First Name *

Last Name *

Date of Birth *

Age

Do you require services with *

Civic - NSW Biala by Civic - Victoria

Exisiting Civic or Biala client *

YesNo

Which services

Street Address *

Postcode

Suburb *

Phone number

email address

Disability

Preferred communication method

Preferred Language

Aboriginal and/or Torres Strait Islander

Yes No Prefer not to say

Is there a legal guardian in place?

Yes No

Details *

Comments

NDIS Information

NDIS number *

Plan start date *

Plan end date *

Funding periods details

Do you have a Support Coordinator? *

YesNo

Support coordinator name *

Organisation name

Support Coordinator email *

Support Coordinator phone Number

Do you have a Plan Manager? *

YesNo

PLEASE NOTE SECTIONS OF YOUR NDIS PLAN MAY BE MANAGED DIFFERENTLY. THERE IS AN OPTION BELOW TO SPECIFY THIS

Plan Manager email address *

Plan Manager Organisation

Are you Self Managed or NDIA managed *

Self ManagedNDIA Managed

Invoice email if self managed *

Do you have a Plan Nominee? *

YesNo

Plan Nominee full name *

Nominee phone number *

Plan Nominee address

Plan Nominee email

Person completing the form

Contact details

Are you the parent/Guardian?

YesNo

Full Name

Relationship to applicant

Contact details same as above

Email Address

Phone Number *

Are you the: *

ParticipantNDIS plan NomineeSupport CoordinatorOther

Full Name *

Relationship to applicant *

Phone Number *

email address

Emergency Contact

Plan Nominee

As above

Full Name

Relationship to applicant

Phone number

email address

Address

Further information

To whom shall we send the Service Agreement? *

Are there any court/intervention orders in place? *

YesNo

If yes please upload details below

Does the participant have any of the following diagnosed health conditions

EpilepsyAsthmaDiabetesSignificant Allergies

If yes, attach any relevant management plans below.

Does the participant use any mobility equipment or assitive technology?

YesNo

i.e wheelchair, communication devices

list equipment

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

Service Required

Choose an Allied Health Service *

Occupational TherapySpeech Pathology

Details of Service

Upload a copy of your referral letter if available

Browse

Nursing Supports

YesNo

Funding Management

NDIAPlan ManagedSelf Managed

Category *

CoreCapacity Building

Funded hours

Details of support *

Behaviour Support

YesNo

Funding Management

NDIAPlan ManagedSelf Managed

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

Funding Management

NDIAPlan ManagedSelf Managed

Line item

15_054_0128_1_301_701_0128_1_3

Funded Hours

Details *

Counselling

YesNo

Funding Management

NDIAPlan ManagedSelf Managed

Line Item

15_043_0128_1_3

Funded Hours

Details

Support Coordination

YesNo

Funding Management

NDIAPlan ManagedSelf Managed

Level *

2: 07_002_0106_8_33: 07_004_0132_8_3

Funded Hours

Details

Psychosocial Recovery Coaching

YesNo

Funding Management

NDIAPlan ManagedSelf Managed

Line Item

07_101_106_6_3

Funded Hours

Details

Is your child over the age of 9? *

YesNo

Early Childhood Teachers only support children until 9 years old

Are these services

NDIA ManagedSelf ManagedPlan Managed

Please provide information on allocated funding amounts.

Are you interested in Group supports?

YesNo

Please let us know if there is a specific group you are interested in

Group sessions change and update due to demand.

One of our Customer Experience Team will contact you to discuss availability.

NDIS Goals

Goal

Are you requesting supports at home? *

YesNo

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 Please ensure all pets are secure in a seperate room for the duration of the visit - exluding service animals

Are any exit doors locked for safety reasons? *

YesNo

Exit DetailsPlease note staff need to be able to exit the property unassisted in an emergency

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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