Referral

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This form is used to refer Participants to PHM Health

Referral

Name
First Last
NDIS Number
Date of Birth
Phone
Mobile Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Disability Type
- Vision Impairment
- Deaf or hard of hearing
- Mental health conditions
- Intellectual disability
- Acquired brain injury
- Autism spectrum disorder
- Physical disability.
Any other diagnosis?
Is this 1st plan?
- Yes
- No
Plan Start Date
Plan End Date
How is the participant’s plan managed?
- Agency
- Plan Manager
- Self Managed
Transport funding
Relationship Status
- Single
- Married
- Defacto
Living Arrangements
- Private rental
- Family
- SIL
- Group home
Issues with Speech
- Yes
- No
Does participant communicate via communication board/device
- Yes
- No
Employment Status
- Employed
- Unemployed
- Study
- N/A
Cultural background
- Indigenous
- Torres Strait Islander
- Indigenous/Torres Strait Islander
Religion
Type of service
- Social & Community Access
Are there any cultural expectations we should be aware of?
Overall aims
Interests
- Walks
- Beach
- Movies
- Music
- Art
- Footy
- Sport
Other Interests
Other relevant information that would be helpful to know about the participant
Psychologist
Plan Manager
Support Coordinator
Support Coordinator organisation
- Kelmax
- Me Well
Next Of Kin
O/T
Behavour Profile
- Aggression Physical or Verbal:
- Agitated:
- Alcohol:
- Apathetic:
- Cognitive problems:
- Confused easily:
- Demanding:
- Depression:
- Drugs:
- Eating Disorder:
- Extraverted:
- Forgetful:
- Frail:
- Hallucinates:
- Hearing Impaired:
- Illiterate:
- Incontinent:
- Insomnia:
- Introverted:
- Kleptomaniac:
- Lonely:
- Obsessive Compulsive:
- Pain:
- Paranoid:
- Seizures:
- Sexual Expression:
- Smoker:
- Suicidal:
- Violent:
- Wanders:
Other Behavior
Shift requirements
Preferred days and times:
Preferred Female or Male
Requirements for S&C/A Transport?
- To appointment
- To do shopping
- To social activities:
Relationships?
- Help to make friends:
- Help to improve current relationships:
- Help finding new social groups/activities:
- Help to connect with family:
Employment & Education?
- Support attending current job/studies:
- Support finding a job:
- Support finding a course:

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