Click 'Next' to start your referral.

Client Details

TitleMrMrsMsMissMaster

First Name *

Last Name *

Preferred Name

Date of Birth *

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Best contact phone number for the client

Best contact email address for the client

Preferred Contact *

PhoneEmail

If suitable, appointment reminders sent to:

PhoneEmail

Address *

Street address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

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Gender identity

Pronouns

Selecting any that are applicable, do you identify as: *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNone

If you have another cultural identity you'd like us to know, please specify.

Is English the client's preferred language?

YesNo

If no, please specify the client's preferred language *

Is an interpreter required? *

YesNoUnsure

Does the client have any diagnosed conditions? Please specify in order of signifance as relevant for this referral. *

Does the client have any medical alerts or allergies? *

YesNo

If yes, please briefly explain *

Who is the client's Legal Guardian or Decision Maker?

Who is the Client's Legal Guardian or Decision Maker *

Me (The Client)Someone else

First Name *

Last Name *

Phone *

Email *

Preferred Contact

PhoneEmail

If suitable, appointment reminders sent to:

PhoneEmail

Relationship to client *

Is this person the client's Emergency Contact? *

YesNo

Is English their preferred language?

YesNo

If no, what is their preferred language? *

Is an interpreter required? *

YesNoUnsure

An additional contact can be added on the next page.

Who do we contact to make an appointment?

Please complete this section if:

• This contact is different to the legal guardian, decision maker, or emergency contact, or

• You want to include a second legal guardian or decision maker.
  

Otherwise, skip this section.

First Name

Last Name

Phone

Email

Preferred Contact

PhoneEmail

Is this person the client's Emergency Contact?

YesNo

Relationship to Client

Is English their preferred language?

YesNo

If no, what is their preferred langauge?

2nd Contact: Is an interpreter required?

YesNoUnsure

Are there any other professionals working with this client?

Please provide details of other professionals working with the client. For example, their name/business name and service provided to the client.

Referral Details

How will this service be funded? *

NDISPrivateOther

NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

How is the plan managed? *

Self managedPlan managedNDIA managed

If yes, please provide the Company Name, Contact Number and Invoicing Email below. *

Who is the plan manager? *

What is their email? *

Is there a plan nominee? *

YesNo

Plan Nominee's First Name *

Plan Nominee's Last Name *

Plan Nominee's Phone *

Plan Nominee's Email *

Does the client already have a Support Coordinator? *

YesNo

Support Coordinator Name *

Support Coordinator's Company *

Support Coordinator Phone *

Support Coordinator Email *

Is there a decision maker appointed for NDIS supports? *

Yes - OPG appointedYes - QCAT orderedNo

Is there a decision maker appointed for finances? *

Yes - Public Trustee managedYes - QCAT appointedNo

If known, please specify dates/hours of support required each week. *If unknown, write 'Unknown.'

Funding Other: Please provide details. *

Social Background and Risk Assessment

Is Child, Youth, Justice, Multicultural Affairs (Child Safety/CYJMA) involved? *

YesNo

If yes, please specify which organisation is involved and the branch location: *

What best describes the client's home living situation? *

HomeResidential Care Home (Child Safety QLD)Supported Independent Living (SIL)Aged Care Residential or Supported LivingFoster CareOther

If other, please specify. *

Occupation or School Name

Please add any other necessary social background information here, not limited to client interests, safety concerns, contact restrictions, or behavioural issues.

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Has the client ever been a Mental Health inpatient?

Yes, voluntarilyYes, involuntarilyYes, bothNo, never

Does the client have any current or previous justice system involvement? *

YesNo

Is there a history of risk of client harm to themselves or others? *

YesNo

Is there a current risk of client harm to themselves or others? *

YesNo

Is there a history of substance abuse? *

YesNo

If yes, please provide details. *

Are there any restrictive practices in place? *

YesNo

Please briefly explain *

If you have a Positive Behaviour Support Plan, please upload it here.

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Services and Referral Reasons

What service/services are you looking to engage with Well Life Services? *

Play TherapyArt Therapy - IndividualArt Therapy - GroupsCounsellingOccupational TherapyPsychologySocial WorkSupport CoordinationCare Coordination

Play Therapy: Previously Diagnosed Conditions. Check all that apply *

Oppositional Defiant Disorder (ODD)Attention Deficit Hyperactive Disorder (ADHD)Post Traumatic Stress Disorder (PTSD)Obsessive Compulsive Disorder (OCD)AnxietyDepressionReactive Attachment DisorderTourette SyndromeConduct Disorder (CD)AutismOtherTest

Other: Please provide details *

What are you hoping to achieve with Play Therapy? *

If applicable, tick any specific issues you are seeking support for:

AnxietyDepressionTraumaFamily issuesSomething else

You answered "Something else." Please briefly explain. *

Art Therapy: Please provide a brief statement for the reason for the counselling referral. *

Counselling: Please provide a brief statement for the reason for the counselling referral. *

Occupational Therapy: Reason(s) for referral *

Psychosocial Functional Capacity AssessmentOther Functional Capacity AssessmentFunctional Capacity Assessment with home and living recommendationsAssistive Technology AssessmentOngoing InterventionOther

Occupational Therapy: Please specify 'other' reason for referral *

Occupational Therapy: Please specify the type of assistive technology the client is looking for. *

Occupational Therapy: Further details of client needs and goals *

Psychology: Reason for Referral *

Psychology: GP's name and contact details

Psychology: If your reason for referral is Psychological assessments please select one of the following: *

Autism and/or ADHD assessmentDiagnostic assessmentLearning and cognition assessmentPsychosocial assessmentRe-assessment of diagnosisOtherN/A - Seeking ongoing therapy

If other, please specify *

Psychology: Please provide information about your key concerns so that we can determine how to best meet the needs of the client. *

Psychology: Current Challenges *

DepressionAnxietyEmotional/mood regulationBehaviouralRisk of suicideDrugs and alcoholChronic PainDisordered eatingLow self-esteemHousing issuesGrief and lossLife changesPoor supportOther

If other, please specify. *

Social Work: Reason for Referral. *

Reason for referral and service required *

Preferred frequency *

WeeklyFortnightlyMonthly

Preferred Frequency *

WeeklyFortnightlyMonthlyAssessment Only

If known, total allowance of funding to determine service provision.

Complete any additional information you'd like us to know.

Does the client require new Support Coordination services? *

YesNo

If Support Coordination is needed, what level has been approved?

Level 1Level 2Level 3Psychosocial Recovery Coach

Does the client already have a Level 2 Support Coordinator?

Yes, I'll provide their details in the next questions.Yes, but I'd like to change to Well Life Services for Level 2 and Level 3 Support Coordination.No, not yet.No, I'd like to use Well Life Services for Level 2 and Level 3 Support Coordination.

Funding: How many hours/what is the monetary amount of Support Coordination or Psychosocial Recovery approved? *

Does the client require new Care Coordination services? *

YesNo

Will Public Holiday Care be required? *

YesNoUnsure

Please outline the reason(s) for seeking new Care Coordination services with Well Life Services.

If known, please specify days/hours of Care Coordination required each week:

Will the client require medication while Well Life Services staff are on-site? *

YesNo

If yes, please specify the type, dosage, and times for medication to be taken. *

Does the client have a Companion Card?

YesNo

Individualised Support Requirements for the client: Behaviours. *

Individualised Support Requirements for the client: Triggers/Phobias/Anxieties. *

Individualised Support Requirements for the client: Strategies. *

Individualised Support Requirements for the client: Strengths. *

Individualised Support Requirements for the client: Personal Hygiene. *

Individualised Support Requirements for the client: Process/advice for on shift absconding including who we should contact. *

Please list 3 NDIS goals for the client: *

Skills Matrix *

Limited AbilityCompetentProficient

Swimming

Limited AbilityCompetentProficient

Riding a Bike

Limited AbilityCompetentProficient

Climbing

Limited AbilityCompetentProficient

Stamina

Limited AbilityCompetentProficient

Completing complex tasks

Limited AbilityCompetentProficient

Following direction

Limited AbilityCompetentProficient

Preparing food

Limited AbilityCompetentProficient

Dressing

Limited AbilityCompetentProficient

CORE SUPPORTS: NDIS Codes that HYPAR can bill under *

Please tick

Category 1 - Assistance with daily life: 01_011_0107_1_1 (Weekday)

Please tick

Category 1 - Assistance with daily life: 01_012_0107_1_1 (Public Holiday)

Please tick

Category 1 - Assistance with daily life: 01_013_0107_1_1 (Saturday)

Please tick

Category 1 - Assistance with daily life: 01_014_0107_1_1 (Sunday)

Please tick

Category 4 - Assistance with social and community participation: 04_104_0125_6_1 (Weekday)

Please tick

Category 4 - Assistance with social and community participation: 04_102_0125_6_1 (Public Holiday)

Please tick

Category 4 - Assistance with social and community participation: 04_105_0125_6_1 (Saturday)

Please tick

Category 4 - Assistance with social and community participation: 04_106_0125_6_1 (Sunday)

Please tick

CAPACITY BUILDING: NDIS codes that HYPAR can bill under: *

Please tick

Category 9 - Increased social and community participation (weekday only): 09_009_0117_6_3

Please tick

Category 9 - Increased social and community participation (weekday only): 09_006_0106_6_3

Please tick

Category 15 - Improved daily living skills (weekday only): 15_037_0117_1_3

Please tick

Appointment Preferences

Select the preferred location to receive Play Therapy *

Well Life Services Toowoomba OfficesIpswichHomeSchoolOther

Please note, appointments away from Well Life Services offices may incur travel costs.

Select the preferred location to receive Art Therapy *

Well Life Services Toowoomba OfficesIpswichTelehealthHomeSchoolOther

Please note, appointments away from Well Life Services offices may incur travel costs.

Select the preferred location to receive Counselling *

Well Life Services Toowoomba OfficesIpswichTelehealthHomeSchoolOther

Please note, appointments away from Well Life Services offices may incur travel costs.

Select the preferred location to receive Occupational Therapy *

Well Life Services Toowoomba Main OfficeHomeSchoolOther

Please note, appointments away from Well Life Services offices may incur travel costs.

Select the preferred location to receive Psychology *

Well Life Services Toowoomba Main OfficeTelehealthOther

Please note, appointments away from Well Life Services offices may incur travel costs.

Select the preferred location to receive Psychology *

Well Life Services Toowoomba Main OfficeIpswichTelehealthHomeOther

Please note, appointments away from Well Life Services offices may incur travel costs.

If you selected School or Other, please specify the name and/or location details. *

If you selected School or Other, please specify the name and/or location details. *

If you selected 'Other,' please specify. *

Preferred days/times for services

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Completion Information

This form has been completed by:

First Name

Last Name

Is the client or the client representative aware of this referral? *

YesNoI am the client or the client representative.

Has the client or the client's representative given consent for this referral? *

YesNo

Please attach any previous service reports or NDIS goals, if relevant.

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Any relevant previous report, NDIS plan, referral form, or medical summaries/diagnosis summaries. This form can accept one attachment. Others can be emailed to hello@welllifeservices.com.au if required.

How did you hear about Well Life Services? *Google/WebsiteSupport CoordinatorMedical TeamEmail marketingNetworkWord of MouthOther

Other: Please specify *

Any additional comments

Signature of referrer *

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Date of Referral *

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