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Referral Process

If you would like to enquire or receive a quote for my 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.  

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I 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:

About the participant / client:

Birthday
Day
Month
Year
Does the person identify as a First Nations Australian?
Is the person an NDIS participant?
Yes
No
Not yet (application pending)
What is your relationship to the participant?
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

(Name, phone, email)

About the services required:

What services are required?
What is the preferred method of service delivery?

(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 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

(Name, Phone, Email)

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

(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.

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