Power Of Grace Care Services Referral Form Supports Referral Form TitleMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle Name *Last Name *Date of Birth *Phone number *Email Address *Street Address *Apartment, suite, etcCity *ZIP / Postal Code *Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweState / Province *Select ProvinceNew South WalesVictoriaWestern AustrliaSouth AustraliaTasmaniaQueenslandNothern TerritoryNDIS Number *Plan Start Date *Plan End Date *Next of Kin *Next of Kin Relationship *Next of Kin Phone number *Next of Kin Email Address *Referrer Name *Referrer Relationship *Referring Organisation (if applicable)Referrer Phone number *Referrer Email Address *Interpreter Required *YesNoInterpreter RequiredLanguagePreferred Worker *FemaleMaleNo PreferencePreferred WorkerPlease select one of the following funding options *NDIS ManagedPlan ManagedSelf-Managed/Private FundsOtherPlease select one of the following funding optionsOther funding please specifyName of Company *Contact person *Phone number *Email Address *Primary Diagnosis / Disability and Comorbidities *Please select if applicableAsthma/AllergiesCommunication SupportsMobility SupportsIf ticked, please provide further details.Services Required (Please Tick) *1:1 Support Access CommunityMeal Planning & Preparation1:1 Support Self-care Activities (personal hygiene)Domestic AssistanceDrop In SupportsContinence ManagementTransport AssistanceSupport CoordinationShort Term Accommodation (STA)Supported Independent Living (SIL)Other (Please state)Services Required (Please Tick)Other (Please state)Support TypeNDIS Support Item NumberCostPreferred Support Day(s) and Time(sOther InformationWeeks of service for the plan period:46 Weeks52 weeksLife of PlanOther (Please state)Weeks of service for the plan period:Other (Please state)Living SituationAloneFamilySupported AccommodationOtherLiving SituationPlease specifySelect all applicableIs the participant living in an isolated area?Is there limited mobile phone coverage?Are there any pets present? (if so, they may need to be restrained at time of visit)Does anyone at the property have a history of being aggressive/violent?Does anyone at the property have a history of alcohol or illicit drug dependence?Are there firearms in the home?Does anyone at the property have an infectious disease?Are there any other factors relating to the safety of our therapists entering the property?If Yes to any questions above, please provide further info:Consent (Please Tick Prior to Submission) *I confirm I have informed the participant and obtained their consent that: (A). Their personal information (including health information) will be shared with Power of Grace Care Services Pty Ltd for the purposes of providing allied health services. (B). Power of Grace Care Services will contact the patient about the services and their nominated Next of Kin Power of Grace Care Services has not been able to contact the participant. (C). If applicable, Power of Grace Care Services may be required to disclose their personal information to the NDIA or plan managers to ascertain eligibility for the services, confirm receipt of services and facilitate their participation in the services. All parties involved with this program are bound by strict obligations of confidentiality and privacy.Send Message
