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Client Referral Form

Refer a client for INREACH Supports services and Christine Court Assisted Living. Complete this form to begin the intake process.

Section 1: Service Type & Referral Information

Tell us what type of service is needed and who is making this referral

Type of Service Required

Important: This selection will determine which sections of the form you need to complete.

NDIS Services

Daily personal activities, participation in community, social and civic activities

Christine Court Assisted Living

24/7 supported accommodation (non-NDIS)

Both Accommodation & NDIS Services

SIL (Supported Independent Living) or Christine Court Assisted Living & NDIS Services

Type of Referral

Self Referral

Family/Friend

Professional

Organization

Urgency Level

Referrer's Full Name

Organization

Contact Phone

Email Address

Relationship to Client

My authority to make this referral and/or provide consent:

I am the client's appointed guardian with authority over accommodation decisions I am the client's appointed guardian (general authority) I have Power of Attorney for the client I am a Public Trustee representative I am a healthcare/support professional referring with client's verbal consent I am family/friend referring with client's knowledge I am making an emergency/duty of care referral I do not have legal authority - consent will need to be obtained from the client

Order/Reference Number (if applicable)

Authority Expiry Date (if applicable)

ℹ️ Self-Referral Selected
Your contact information will be automatically populated from the client details you provide in Section 2.

Section 2: Client Details

Information about the person requiring support

First Name

Last Name

Preferred Name

Date of Birth

Current Age

Gender

Indigenous Status

Street Address

Suburb

State

Postcode

Phone Number

Email Address

Preferred Contact Method

Section 3: Guardian & Financial Management

Legal guardianship and financial management arrangements

Public Guardian: Makes health and lifestyle decisions when appointed by NCAT or the Supreme Court

Is the client under the Office of the Public Guardian?

Yes

Application pending

Unknown

Type of Guardian

Guardian Details

Guardianship Order Number

Public Trustee: Manages financial affairs for people unable to make financial decisions

Is the client under the Public Trustee?

Yes

Application pending

Unknown

Trustee Details

Trustee Account Number

Financial Management Arrangement

Financial Manager Details

Does the client have an Enduring Power of Attorney?

Yes

Unknown

Power of Attorney Details

Bank Account Management

Section 4: Income & Benefits

Income sources and government benefits

Primary Income Source

Centrelink Customer Reference Number (CRN) Found on Centrelink letters and online account

Does the client have a Centrelink Representative Payee?

Yes

Representative Payee Details

Receives Commonwealth Rent Assistance?

Yes

Unknown

Other Benefits/Concessions

Pensioner Concession Card Health Care Card Companion Card Mobility Allowance Essential Medical Equipment Payment None of the above

Section 5: NDIS Plan Information NDIS Services Only

Details about the client's NDIS plan and funding

Does the client have an active NDIS plan?

Yes - Active plan

Application pending

Plan expired - renewal in progress

No NDIS plan

NDIS Number

Plan Start Date

Plan End Date

Plan Management Type

Plan Manager Details

Does the client have a Support Coordinator?

Yes

Support Coordinator Details

Funding Categories in Plan

Assistance with Daily Personal Activities Assistance to Access Community Participation in Community, Social and Civic Activities Transport Consumables Assistive Technology Home Modifications Specialist Disability Accommodation Support Coordination

Section 6: Christine Court Accommodation Christine Court Only

Specific information for Christine Court Assisted Living

Level 2: Includes daily personal care via INREACH Supports (NDIS-funded)
Level 3: Includes accommodation with basic support only

Christine Court Support Level Required

Level 2 - Daily Personal Care via INREACH Supports

For NDIS participants requiring daily 1:1 assistance with personal care, medication, and household tasks

Level 3 - Basic Support Only

Weekly cleaning, linen changes, medication prompts, no daily personal care included

Unsure - Need Assessment

Require assistance determining appropriate level

Room Preference

Single room

Shared room

No preference

Payment Method for Christine Court

Centrelink Direct Deduction - Fees deducted directly from pension payments Centrepay - Regular deduction service through Services Australia for bills and rent Public Trustee - Payment managed through trustee account Alternative Payment Method - Including Bank Transfer, Direct Debit, or other arrangements (please specify)

I consent to Christine Court Assisted Living arranging accommodation fee deductions through Services Australia

Alternative Payment Method

Preferred Move-in Date

Current Accommodation Situation

Reason for Seeking Christine Court Accommodation

Specific Support Needs at Christine Court

All meals provided Medication prompts and management 24/7 on-site staff and security Room cleaning and laundry

Section 7: Medical & Health Information

Relevant medical information to ensure appropriate support

Primary Diagnosis

Primary Disability Category

Secondary Conditions

Mobility Status

Medication Management

Mobility Aids Used

None Walking stick Walker/Walking frame Manual wheelchair Power wheelchair Mobility scooter Hoist transfers required Other

Communication Methods

Verbal communication Australian Sign Language (Auslan) AAC device Picture cards/PECS Written communication Interpreter required Other

Current Medications

Allergies & Dietary Requirements

Current Medical Providers

Section 8: Support Needs Assessment

Help us understand the level of support required

Personal Care (bathing, dressing, grooming)

Independent

Minimal Support

Moderate Support

Full Support

Meal Preparation

Independent

Minimal Support

Moderate Support

Full Support

Household Tasks

Independent

Minimal Support

Moderate Support

Full Support

Transport & Community Access

Independent

Minimal Support

Moderate Support

Full Support

Money Management

Independent

Minimal Support

Moderate Support

Full Support

Social & Emotional Support

Independent

Minimal Support

Moderate Support

Full Support

Behavior Support Needs

Does the client have a Positive Behavior Support Plan?

Yes - Current plan

Yes - Needs updating

Unknown

Communication Support Needs

Daily Routine Support Requirements

Section 9: Risk Assessment & Emergency Information

Identify any risks and emergency contacts

Identified Risks

Falls risk Choking risk Wandering/Absconding risk Self-harm risk Aggression risk Seizure risk Pressure injury risk Aspiration risk Manual handling risk Infection control risk Environmental hazards Financial vulnerability Social isolation risk Medication management risk Substance use risk Risk of exploitation No identified risks

Risk Management Strategies

Primary Emergency Contact

Name

Relationship

Phone

Secondary Emergency Contact

Name

Relationship

Phone

Preferred Hospital

Advanced Care Directive?

Yes

Unknown

Section 10: Service Requirements & Consent

Specific services needed and consent for service provision

Required NDIS Services

Personal Care Domestic Assistance Community Access Social Support Transport Respite Care Supported Independent Living (SIL) Short Term Accommodation (STA) Allied Health Services Nursing Care Meal Preparation Medication Support

Preferred Service Days

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Hours Per Week Required

Requested Service Start Date

Supporting Documents

Upload NDIS plan, medical reports, behavior support plans, guardianship orders, etc.

Click to upload or drag and drop PDF, DOC, DOCX, JPG, PNG (max 10MB each)

Information Sharing Consent

Select all organizations you consent to share information with

Required Organizations

INREACH Supports

Service-Specific Organizations

National Disability Insurance Agency (NDIA) Services Australia/Centrelink Christine Court Assisted Living

Optional Organizations

Office of Public Guardian Public Trustee Healthcare providers Emergency services

Service Authorization Consents

I acknowledge that client consent is required for INREACH Supports and/or Christine Court Assisted Living to provide services

I acknowledge that client authorization is required for INREACH Supports to make NDIS claims

I acknowledge that client authorization is required for accommodation fee deductions through Services Australia

ℹ️ Important:

Legal Agreements

I have read and understood the Privacy Policy

I agree to the Terms and Conditions of service

Additional Notes

Submission Details

Your Name

Your Role/Relationship

Your Email

Your Phone