Empower Riverina
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Referral Form
All fields are required. For unavailable information, please put 'N/A' where applicable.
Referral Type
Participant Referral
Organisation Referral
NDIS Ref. #
NDIS Plan Dates
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Participant Details
Name
Date of Birth
Address
Phone
Email
Interpreter Required? (Y/N)
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LAC Details
LAC #
Phone
Email
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Support Coordinator
Support Co. / Organisation
Phone
Email
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Plan Manager
Organisation
Phone
Email
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Next of Kin
Name
Address
Phone
Email
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Participant Health & Needs
Diagnosis
Risks / Behaviours
Medical Conditions
Reason for Referral
Relevant NDIS Goals
Supports Needed
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Legal Authority / Guardianship
Is the participant currently under a formal guardianship order?
Yes
No
Name of Appointed Guardian
Type of Guardianship
Guardian Contact Phone
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Power of Attorney
Has the participant appointed a POA or EPOA?
Yes
No
Not Applicable
Name of Appointed Attorney
POA decision scope (e.g. Financial, Medical, General)
Attorney Contact Phone
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Authorised Representative
Is there a legally authorised representative?
Yes
No
Legal Role / Authority
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Melba's Hub Day Program
Preferred Days
Support Ratio (1:1, 1:2, 1:3)
Transport Required? (Y/N)