Referral Form – Arcadia Community Care

Request for Disability Support Services

Referral Date

Participant Contact Information

Title

Referral Type

Participant First Name

Participant Last Name

NDIS Number

Participant Date of Birth

Participant Gender

Male Female Prefer not to say Other (Please specify)

Please specify

Participant Email

Participant Mobile

Phone

Participant Address

Street Address

State

City / ZIP / Postal Code

What type of accommodation does the participant live in?

Does the Client have a Parent/Guardian or Nominee?

Yes No

Please specify

Plan Start Date

Plan End Date

Is the participant able to receive & sign a service agreement?

Yes No

By default, unless otherwise specified, a service agreement will be sent to the participant, with a copy to the referrer.

Please enter the email of who will be signing the service agreement.

Support Information

Our team try very hard to ensure that participants are linked with their prefered clinicians and team members. Let us know if you have a gender preference.

I prefer a Male support worker I prefer a Female support worker I dont have a preference - any gender support worker is fine.

Is this a firm requirement?

Yes, the support worker MUST be my preferred gender. No, another gender is fine if my preferred is not available.

Which supports does the participant require?

Supported Independent Living (SIL) Specialised Disability Accommodation (SDA) In-Home Support Community Participation Support

You may select more than one option.

Please tell us more about the diagnosis/condition(s) of the participant.

What is known about the client’s presenting situation and circumstances?

Are there any BSPs or Restrictive practices in place?

Please indicate the schedule required for the supports (times and/or days)

What level of support does the participant require?

Standard High Intensity Not sure

Does the client require support public holidays?

Yes No

Additional Information - Please outline any additional information you'd like us to know regarding the participant or the referral.

Please select the fund management method

Plan Manager Organisation Name

Email to send invoices to: You can usually find this information on your plan manager's website.

Does the participant have a Support Coordinator?

Yes No

To allow your referral process to be as smooth as possible, please consider uploading a copy of your NDIS plan. This is not mandatory, however, it helps us to view your goals and verify any information we need for your service bookings. You may also choose to provide us with any additional documentation to assist with your service delivery, such as Medical or Allied Health reports, Participant Profiles or Behaviour Support Plans.

Max. File Size 256MB | Upto 10-Multiple Files You Can Upload

How did you hear about us?

ARCADIA Community Care

We chose the name ‘Arcadia’ because it represents an ideal place of peace, connection, and belonging. For us, it’s more than just a name. It reflects our commitment to redefining and transforming what home means for you.

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