Make a Referral

First Name

Last Name

Date of Birth

Gender
—Please choose an option—Female (she/her)Male (he/him)Non-binary (they/them)TransgenderGender neutralPrefer not to say

Is the participant...

Torres Straight OriginAboriginalCulturally And Linguistically Diverse (CaLD)None of these

Language

EnglishInterpreter requiredAuslanAssistive technologyOther

Email

Phone

Address

Primary Diagnosis/Disability

Secondary Diagnosis/Disability

Status
—Please choose an option—MarriedSingleDefactoSeparatedWidowedDivorced

Children
—Please choose an option—YesNo

Living Situation
—Please choose an option—Living independentlyLiving with a carer or relativeHomelessOther

First Name

Last Name

Email

Phone

Relationship to participant

Address

Is this an emergency contact?
—Please choose an option—YesNo

First Name*

Last Name*

Email*

Phone*

Organisation*

Position*

Address*

How did you hear about Sunflower Services?
—Please choose an option—Family/FriendGoogleNDIS Provider ListingAdvertisementFacebookOther

NDIS Number

Plan Start Date

Plan End Date

Funding available in plan

Hours of support per week

Upload NDIS Plan (if applicable)

Which of our services does the participant require?

Support WorkPsychosocial Recovery CoachingSupport Coordination

General Information

Presenting Risks/Complexities

Is the Participant supported by only one worker?

YesNo

What are the Participant's Short-Term NDIS goals?

What are the Participant's Long-Term NDIS goals

Does the Participant have any allergies?

YesNo

Does the Participant have any Health/Medical conditions?

Participant's preferred method of communication

TextingCallingEmailOther

Participant's living arrangements

—Please choose an option—SILOOHCLiving in own home with family or carerLiving in own home independentlyILO

Is the Participant at risk of choking, seizures, or anaphylaxis?

—Please choose an option—YesNo

Is the Participant under Public Guardian?

—Please choose an option—YesNoDo not wish to disclose

Is the Participant under care of the minister?

—Please choose an option—YesNoDo not wish to disclose

Is the Participant under TAG (Trustee and Guardian)?

—Please choose an option—YesNoDo not wish to disclose

Plan nominee?

—Please choose an option—YesNoDo not wish to disclose

Is assistance with medication and medication administration required?

—Please choose an option—YesNo

Is the home easy to locate?

—Please choose an option—YesNoUnknown

Is onsite parking available for support workers?

—Please choose an option—YesNoUnknown

Are there any slip, trip or falling hazards outside or inside the home?

—Please choose an option—YesNoUnknown

Is there a pet or pets?

—Please choose an option—YesNoUnknown

Is there a clearly designated entrance and exit for staff to access the home?

—Please choose an option—YesNoUnknown

Is the Participant at risk of absconding?

—Please choose an option—YesNoUnknown

Does the Participant require a two-person visit for safety reasons?

—Please choose an option—YesNoUnknown

Are there any safety concerns Sunflower Services need to be aware of?

—Please choose an option—YesNoUnknown

How is the participant managed?

Plan ManagedSelf ManagedAgency Managed

Which office should we direct your referral to?
Newcastle (NSW)Adelaide (SA)

Additional Comments

Upload Behaviour Management Plan (if applicable)

Upload OT Assessment (optional)

Upload Risk Assessment (optional)

Upload any other relevant collateral (optional)

Do you wish to join our email list to receive newsletters, uplifting stories, and updates on our services, including Supported Independent Living (SIL) and NDIS accommodation options?

YesNo

Has the participant/guardian consented to this referral?*

YesNo