Refer a Client | Inclusive Minds

Participant details

Tell us about the person you're referring to Inclusive Minds.

Personal Information

First Name * Please enter the participant's first name

Last Name * Please enter the participant's last name

Date of Birth

NDIS Number

Gender / Pronouns

Interpreter Required?

Preferred Language

Contact & Location

Mobile * Please enter a contact number

Email Address

Residential Address / Suburb

Disability & Diagnosis

Primary Disability / Diagnosis

NDIS Plan End Date

Services requested

Select all services you believe the participant would benefit from. We'll confirm suitability when we make contact.

NDIS Services

Support Coordination

Support Item 07_001

Recovery Coaching

Psychosocial support

Community Access

Support Item 04_210

Daily Activities

Support Item 01_XXX

Reason for Referral

Background & Support Needs * Please provide a reason for the referral

Any specific goals or priorities?

Urgency

NDIS Plan copy available?

Your details

Tell us about yourself so we can follow up and acknowledge your referral.

Referrer Information

Your Full Name * Please enter your name

Organisation / Agency

Position / Role

Participant's consent given?

Your Phone * Please enter your phone number

Your Email * Please enter a valid email address

Additional Notes

Anything else we should know?

Review your referral

Please check the details below before submitting. You can go back to make changes.

Participant Details

Name—

Date of Birth—

NDIS Number—

Mobile—

Email—

Suburb / Address—

Diagnosis—

Interpreter needed—

Services & Reason

Services requested—

Reason for referral—

Urgency—

Plan copy available—

Referrer

Name—

Organisation—

Role—

Phone—

Email—

Consent given

By submitting this referral you confirm the participant has given consent (or will provide it) and that the information provided is accurate to the best of your knowledge. Information is handled in accordance with the Privacy Act 1988.

✅

Referral submitted!

Thank you — your referral has been sent to Inclusive Minds. Rifat will be in touch with you within one business day to discuss next steps.

A copy has been opened in your email client for your records.

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