Referral process

If you would like to enquire or receive a quote for our services or you are a third-party referrer and would like to request services for one of your participants, please fill out the referral form below.

We will respond to your request within 1 business day.

Referral Form

Please complete this form with as much detail as possible. The information provided helps determine whether the service requested is appropriate and how we can best support you or the participant.

About the referrer / person filling out this form:

First name

Last name

Phone

Email

Company name

About the participant / client:

Name participant / client:

Birthday

Day

Month

Year

Address

Phone

Email

Does the person identify as a First Nations Australian?

Yes, Aboriginal Australian

Yes, Torres Strait Islander

Neither

Is the person an NDIS participant?

Yes

No

Not yet (application pending)

Is the person aware of this referral and have they provided consent?

Yes

No

N/A (i.e. participant not able to provide consent)

Does the person have a legal decision maker or otherwise allocated nominee?

Yes, Public Guardian (OPA)

Yes, Legal Guardian

Yes, Plan Nominee

No

Guardian / Decision maker contact details:

(Name, phone, email)

About the services required:

What services are required?

Behaviour Support Services

Functional Behaviour Assessment

Functional Capacity Assessment (psychosocial disability only)

Therapy / Capacity Building

Individual Counselling & Therapy

Clinical Supervision

What is the physical location, suburb, or address where services are requested?

What is the preferred method of service delivery?

In-Person / Face-to-face

Telehealth

A combination of both

Consultation basis only

Please provide details about the reason you are requesting these services:

Please upload any relevant or additional documentation.

(i.e. GP mental health care plan, assessment plan, reports)

About the NDIS Plan (if applicable):

Is there a current NDIS Plan?

Yes

No

NDIS Plan Number:

NDIS Plan Start Date

Day

Month

Year

NDIS Plan End Date

Day

Month

Year

Is your funding plan a PACE Plan?

Yes

No

Unsure

Type of funding management:

Agency Managed

Plan Managed

Self Managed

Unsure

Do you have a support coordinator?

Yes

No

Support Coordinator contact details:

(Name, Phone, Email)

About your plan manager (where to send invoices to):

Name of Plan Management Compnay:

Plan Manager contact details:

(Name, Phone, Email)d

By submitting this form I give consent to Core Counselling & Consultancy to assess suitability for the requested services and contact myself, my nominee, or decision maker.