Referral Form Ready to recommend someone for our services? Please fill out the referral form below. Required Services NDIS Services - Support Coordination NDIS Services - Social Work NDIS Services - Psychosocial Recovery NDIS Services - Coach Counselling NDIS Services - In-home and Social Support NDIS Services - Group Activities NDIS Services - School Holiday Programs NDIS Services - Nursing Care NDIS Services - Overnight Support Aged Care Service - Home Care Packages Supported Independent Living (SIL) Short-term Accommodation and Respite Client Details Name Date of Birth Gender Male Female Other NDIS Number Plan Start Date Plan End Date Mobile Number Email Residential Address Next of kin Name Relationship to Client Contact Details Referrer's Details Name Organisation Contact Details Disability/Medical Conditions Funding Stream NDIS: Self-managed NDIS: Plan-managed NDIS: NDIA-managed Home Care Package CHSP If you have selected NDIS: Plan-managed, or a Home Care Package, please provide the following payment details: Name of Fund/Plan Manager Contact Client's Statement: I have read and agreed to the following: • Information within these records will be shared with other staff within The Fig Trees when and only when staff require the information to carry out their duties. • I understand that all information obtained will be kept confidential. • To the best of my knowledge, the information provided in this form is true and correct • I give consent to The Fig Trees to contact myself, my referrer and/or my plan manager to discuss support plans and budgets. If you are making this referral on behalf of your client/ family member, please confirm that you have obtained their consent to do so. Yes I do Signature Name of Signatory Date Submit