Referral Form

Please fill out the referral form below.​

Details of NDIS Participant

In this section, please include the details of the NDIS participant who would like to access our services.

Name of Participants 
Date of Birth 
Location/ Suburb
Phone Number of Participant 
Preferred contact method  
Email of person filling out referral  
NDIS Number 

The Plan Manager is the person/provider who manages the funds of a NDIS participant (i.e., pay invoices). 

Details of Person Making Referral

(i.e., a support coordinator). If same as above, please leave blank.​

Name
Email Address
Phone Number 
Organization & Position
Relationship to NDIS Participant
Service Request
Details of Services Required 

Please include the type of service the NDIS participant would like to access. Please also include any other background information that may be of use to assist with the referral (i.e., history of diagnosis, preference in support workers, times of the day and week the participant would like to access, etc).

Are there any risks or hazards we should be aware of (environmental/physical risks at the property of the participant, behavioural risks, or any other type of risks)?
If yes, please provide details or please upload risk assessment below

File Upload
Browse File

Please upload any documentation that you feel may assist us with this referral.

Has the NDIS participant consented to this referral? 

HOW IT WORKS

We understand that engaging with some service providers can be a long and complicated process. Here at AdaptCare, we have made the process as simple and easy as possible. This is how it works:

Step 1: Get in touch with us

Complete the referral form above, submit an online enquiry or call us on (03) 9005 6778 / 0499 824 651

Step 2: We will contact you

Our team will respond to your referral request to discuss our NDIS mental health services and how we can help support you.

Step 3: We will commence support

If you were happy with the meet and greet and wish to proceed with AdaptCare, our support services will start.

SUBMIT AN ONLINE ENQUIRY

If you would like to discuss our services, please submit an enquiry below or call us on (03) 9005 6778 / 0499 824 651.

Thanks for submitting!

  • Facebook
  • LinkedIn