NDIS Referral Form

Make a Referral

NDIS Referral FormSupport at Home Referral Form

NDIS Referral Form

Complete this form to refer yourself or another participant to Dolare Care. Our team will contact the nominated person to discuss support needs, preferences and service availability.

Fields marked are required.

Step 1 of 5

1. Referrer details

Full name *
Organisation (optional)
Position or relationship to the participant (optional)
Phone number *
Email address *

Preferred contact method *

PhoneEmailOther

Please specify your preferred contact method *

Who are you referring? *

MyselfSomeone else

2. Participant and NDIS plan details

The referrer details from Step 1 will be used as the participant’s contact details.

Participant Details

Full name *
Preferred name (optional)
Date of birth *
Phone number (optional)
Email address (optional)
Preferred language (optional)
Home address *

Dates use the Australian DD/MM/YYYY display format where supported by the browser.

How is the participant’s NDIS plan managed? (optional)

Plan-managedSelf-managedNDIA-managedUnsure

3. Health and safety information

These questions are optional. Full medical reports are not required at the referral stage.

Does the participant have any relevant physical health conditions? (optional)

YesNo

Please provide relevant details, including any support needs or safety considerations.

Does the participant have any mental health or psychosocial support needs? (optional)

YesNo

Please provide relevant details, including any support needs or safety considerations.

Does the participant have an intellectual, neurological or cognitive disability? (optional)

YesNo

Please provide relevant details, including any support needs or safety considerations.

Are there any behaviours of concern or known safety risks? (optional)

YesNo

Please provide relevant details, including any support needs or safety considerations.

4. Services and preferred support arrangements

Requested services *

Assistance with Personal ActivitiesHousehold TasksCommunity ParticipationTransport AssistanceDevelopment of Daily Living and Life SkillsAssistance with Daily Tasks in Shared LivingGroup and Centre-Based ActivitiesOther/Unsure

Please provide further details about the support required. (optional)

Preferred commencement date (optional)
Preferred days (optional)
Preferred times (optional)
Approximate support hours required per week. (optional)
Support worker gender preference, if any. (optional)
Support worker language preference, if any (optional)
Cultural, religious or personal preferences, if relevant (optional)
Other support worker matching preferences (optional)

Dates use the Australian DD/MM/YYYY display format where supported by the browser.

5. Urgency and referral source

When is support required? *

As soon as possibleWithin 1–2 weeksWithin one monthPlanning for the future

Who should we contact about this referral? *

ReferrerParticipantAnother person

Contact person’s full name *
Relationship to the participant (optional)
Phone number (phone or email required)
Email address (phone or email required)

Preferred contact method (optional)

PhoneEmailOther

Please provide the contact person’s name and either a phone number or email address.

Referral source (optional)

Support CoordinatorHealth care professionalSchool or community organisationFamily member or friendOnline searchSocial mediaReferred by someoneOther

Consent and submission

Do you have the participant’s consent, or appropriate authority, to submit this referral? *

YesI am the participantNo

This referral cannot be submitted without the participant’s consent or appropriate authority.

I confirm that the information provided is accurate and that I have the participant’s consent, or appropriate authority, to submit this referral. I understand that personal information will be handled in accordance with Dolare Care’s Privacy Policy.