NDIS New Client Referral Form

Participant Details

First Name *

Last Name *

Date of Birth *

Address (Street, Suburb, Postcode, State) *

Mobile *

Email *

NDIS Number *

Parties

This referral is between:

Participant Full Name *

and

Practice Name *

Plan Management

Plan Type *

Plan ManagedSelf ManagedPrivate

Contact for Appointment Booking

Best Contact for Appointment Booking *

ClientSupport CoodinatorNext of Kin/Emergency ContactOther (Please Specify)

Client Contact Name and Relationship to Client *

Client Contact Number *

Support Coordinator

Name

Company

Phone

Email Address

Services Required

Speech Pathology

Psychology

Physiotherapy

Occupational Therapy

Functional Capacity Assessment & Report

Complex Functional Capacity Assessment & Report (20+ hours)

Reason for Referral *

Diagnosis/Past Medical History

Diagnosis *

Past Reports/Relevant Documents

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NDIS Plan/Schedule of Supports

Please upload current plan

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Service Start Date *

Plan End Date *

Funding breakdown for required service(s) *

Provider responsibilities

The Provider will:

Agree to review the provision of supports with the Participant at least once a year, where required.
Liase with any other relevant service providers or support staff where necessary, for the best outcome for the Participant.
The Provider will provide mutually agreed supports that meet the Participant's needs at mutually agreed times.
Communicate effectively, openly and honestly in a timely manner.
Treat the Participant with respect and courtesy.
Consult the Participant on decisions about how and when supports are provided.
Provide information to the Participant about management of complaints and disagreements, and any relevant cancellation policy.
Listen to the Participant's feedback and act responsively to resolve problems.
Provide at least 8 hours notice if a scheduled appointment for providing supports needs to be changed.
Give the Participant sufficient notice if any of the Provider’s supports offered under this service agreement need to be ended or varied.
Keep the Participant's privacy and confidential information protected.
Provide supports in compliance with all relevant laws and regulations, including the National Disability Insurance Scheme Act 2013 and the Australian Consumer Law.
Keep accurate records of the supports provided to the Participant.
Issue regular invoices and statements of the supports delivered to the Participant.

Payments

Lift Health Group will request payment following the delivery of those services. Lift Health Group requests payment be made within 7 days of that service.

Plan Manager Name/Company *

Invoice/Billing Email Address *

Pricing

Lift Health Group charge as per the 2023-2024 NDIS Price Guide. Lift Health Group ensures to spread travel costs among our patients where possible. Please note Lift Health Group aims to create the most cost effective option for our clients, with our unique service delivery model making this possible. More information regarding our pricing can be found at https://lifthealthgroup.com.au/ndis-terms-and-conditions/.

Cancellation Policy

If for any reason the Participant needs to cancel an appointment, we understand. However, we kindly ask that you give us at least 2 business days’ prior notice. Our trips from Adelaide to regional, rural, and remote areas are pre-arranged months in advance.

If the Participant provides less than 2 business days’ prior notice of cancellation of an appointment, the Provider will charge the full price for scheduled support and travel (because we will have our flights pre-booked). Thank you for your understanding.

If the Provider needs to cancel an appointment (due to events that are outside of our control, such as sta ff illness or poor weather conditions), we will:

Notify the Participant as soon as practicable; and
Reschedule the provision of the Participant’s support.

I understand and agree to the cancellation policy *

Home Risk Assessment

If you require services in your home, you are required to fill out this form https://lifthealthgroup.snapforms.com.au/form/home-visit-safety-assessment

Preferred Appointment Location *

HomeSchool (Please specify name and address below)Other (Please specify below)

If Other/School Details

Terms and Conditions

Lift Health Groups Terms and Conditions can be found at https://lifthealthgroup.com.au/ndis-terms-and-conditions/

Where did you hear about Lift Health Group? *