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SILS Referral
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NDIS Referral
SILS Referral
SILS Referral
Consumer Details
Name
*
First
Last
DOB
Date Format: DD slash MM slash YYYY
Gender
Gender
Male
Female
Other
Gender other
*
Are you
Torres Straight Origin
Aboriginal
Culturally And Linguistically Diverse (CaLD)
None of these
Phone
Email
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Diagnosis/Disability
Secondary Diagnosis/Disability
Status
Status
Married
Single
Defacto
Separated
Widowed
Divorced
Children
Yes
No
Living Situation
Living Situation
Living independently
Living with a carer or relative
Homeless
Other
Living Situation other
*
Guardian/Primary Carer Details
Carer Name
First
Last
Relationship to consumer
Carer Phone
Carer Email
Carer Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Is this an emergency contact?
Yes
No
Referrer Details
Referrer Name
*
First
Last
Organisation
*
Position
*
Referrer Phone
*
Referrer Email
*
Referrer Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
NDIS Details
NDIS Number
Planned Start Date
Date Format: DD slash MM slash YYYY
Planned End Date
Date Format: DD slash MM slash YYYY
Service Category being requested for Consumer: (Please fill in where relevant)
Assistance With Daily Life Tasks In A Group Or Shared Living Arrangement
Assistance with Daily Self Care (Core Supports)
Assistance to Access Community (Core Supports)
Specialist Coordination
Coordination of Supports
Increase Social and Community Participation (Capacity Building Supports)
Improved Daily Living Skills (Capacity Building Supports)
Improved Living Arrangements (Capacity Building Supports)
Funding Available In Plan
Hours Of Support Per Week
How Did You Hear About HCG?
How Did You Hear About HCG?
Please Select
Family/Friend
Google
NDIS Provider Listing
Advertisment
Facebook
Other
How Did You Hear About HCG other
*
Introduction to Consumer
General Information
Please indicate consumer’s current overall situation, general background information, history, like/dislikes, etc., (This avoids the consumer from repeating his/her story during the initial meeting with HCG)
Has the Consumer/Guardian consented to this referral?
*
Yes
No
SILS Compatibility Assessment
Do you have any access or mobility requirements?
Yes
No
Access or mobility requirements details
*
If yes, please provide details (Some examples include, slip/trip/fall hazard, walking frames, railings, wheelchair, stairs, hoist requirement, home modifications)
Do you require assistance with Communication?
Yes
No
Assistance with Communication details
*
If yes, please provide details
Can you share accommodation with the opposite gender?
Yes
No
Sharing accommodation with the opposite gender details
*
If no, please provide details as to why
Do you have any specialised Transport requirements?
Yes
No
Specialised Transport requirements details
*
If yes, please provide details such as; I need a specific vehicle, I wear a harness, seat belt guard, child lock
Do you have any special dietary requirements?
Yes
No
Special dietary requirements details
*
If yes, please provide details
Do you have any behaviours or specific risks to mention?
Yes
No
Behaviours or specific risks details
*
Please indicate any risks/complexities identified by your organisation and attach any risk assessments or Behaviour Support Plans if available.Please also note any concerns or prior history around, absconding, verbal/physical aggression, self-harm, property damage, sexualised behaviours and criminal history.
Behaviours or specific risks files
*
Drop files here or
Have you been evicted from private/government or SIL housing before?
Yes
No
Evicted from private/government or SIL housing details
*
If yes, please provide details
Do you have any approved Restrictive Practices?
Yes
No
Approved Restrictive Practices details
*
If yes, please provide details attach relevant supportive documentation
Approved Restrictive Practices files
*
Drop files here or
Do you have any other special needs that need to be considered?
Yes
No
Any other special needs details
*
If yes, please provide details such as; I have hearing impairment, vision problems etc.
Do you take any current medications?
Yes
No
Current medications details
*
If yes, please provide details
Medical Professionals and Services who Support Me
(Doctors, OT’s, Phycologists, Dentists, day programs, other organisations)
Name 1
First
Last
Phone 1
Email 1
Address 1
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Occupation 1
Contact 2
Name 2
First
Last
Phone 2
Email 2
Address 2
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Occupation 2
Contact 3
Name 3
First
Last
Phone 3
Email 3
Address 3
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Occupation 3
Contact 4
Name 4
First
Last
Phone 4
Email 4
Address 4
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Occupation 4
Family and Relationships Network
Regular family contact occurring that we should encourage whilst in HCG accommodation?
Name 5
First
Last
Phone 5
Email 5
Address 5
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Details 5
Contact 2
Name 6
First
Last
Phone 6
Email 6
Address 6
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Details 6
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