Referral Form

Are you the client or are you referring on behalf of a client?:

Client's Representative / Guardian

Support Coordinator

Other

Child's Information

Child’s First Name *

Child's Last Name *

NDIS number: *

NDIS Plan Start Date: *

NDIS Plan End Date: *

Please tell us your child’s NDIS Goals here (or you can attach a copy below) - Note: Referral cannot be accepted without this detail. *

Please attach NDIS goals here if you haven't completed above.

Child's Date of birth: *

Address *

Street Address

City

State

Country

Postal code

Does the child identify with any cultural considerations or special needs/considerations related to their identity?:

Yes

No

Prefer not to say

Does the child require an interpreter?:

Support Coordinator Details - Optional

Support Coordinator First Name:

Support Coordinator Last Name:

Support Coordinator Organisation:

Support Coordinator Email:

Support Coordinator Phone:

Funding Information (Plan and Self Managed only)

Funding Arrangements: *

Portal (Is the participant's plan on)

Please complete the following details if you select Plan Managed.

Plan Manager Provider:

Plan Manager Email:

Gaurdian / Parent's Information

Parent/Guardian’s First Name

Parent/Guardian’s Last Name

Relationship to the child

Mother

Father

Other

Parent/Guardian’s Email (Note: This will be the email used for implementation of Fairy Mail)

Parent/Guardian’s Mobile Number (Note: This will be the phone number used for implementation of Fairy Mail)

Referral Information

What have you done so far to achieve your child’s goals? *

Please share as much information in this section to help us customise your Fairy Mail

Please share information about your child’s diagnosis *

Please share information about your child’s strengths *

Please share information about your child’s challenges *

Please share information about your child’s special interests *

Please share examples of what triggers your child to have a melt-down. Eg. Sophie has a melt-down when her sibling touches her doll collection. Ben has a melt-down when the iPad is removed or turned off. Greg has a melt-down when there is a transition between activities. *

Please share examples of what behaviours your child has when they are in a melt-down. Eg. Sophie tries to bite and kick. Ben will throw himself to the floor until the iPad is turned on. Greg will scream and run away. *

Please share examples of what worries or anxieties your child has. Eg. Sophie is anxious about going to the shopping centre because the noise overwhelms her. Ben is anxious about going to school because he doesn’t like asking for help or to look different to the other kids. Greg avoids making new friends because he does not have confidence or skills to play with other children or have conversations *

Is there anything else you would like us to know about your child? *

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