Registered NDIS providerMelbourne and Port Lincoln
Contact usMake a referral
Outcomes Lab

Intake Form

This takes under 10 minutes.

To save you time, we ask that this form is completed after we've discussed the referral and confirmed we can help. Haven't made a referral yet? Make a referral first.

When you complete this form, it helps to have the NDIS plan and funding details handy.

Step 1 of 8

Referrer Details

Relationship to Client

If the relationship isn't listed, choose Other and type it in.

How did you hear about us?
Before you start

We appreciate you taking the time to complete this form carefully.

Client Details

If different to first name

Client Gender

Client Address

State
Does the client manage their own phone and email communication?

If no, please provide the details of the primary contact person later in the form.

Client Background
Client Preferred Communication Method
Does the client require an Interpreter?

Key Contacts

Does the client have a Support Coordinator?
Does the client have a Plan Nominee?
Does the client have any other Key Contacts?

To support coordinated care, please provide details of any other key people involved, such as family members, support coordinators, house managers, or allied health practitioners not already listed.

Client Health Summary

Supporting Documentation

Please upload any relevant documents, such as:

  • Diagnosis or assessment reports
  • Allied health reports (for example OT, speech pathology or psychology)
  • Medication or treatment plans
  • Specialist letters or hospital discharge summaries

Therapy Requirements

Please describe the reason for this referral, including key concerns, support needed, and desired outcomes.

Are there any time constraints for this referral?
Is a report required?
Service(s) Requested
Do you need a support person at the initial meeting?

Plan and Funding Details

Is this an NDIS referral?

Home & Community Safety Check

Mandatory Safety Screening

Completing this section is required for us to assess our ability to deliver services safely. Please note that we are unable to commit to your services or prepare a Service Agreement without this information.

Please answer each of the following

Is the property easy to find?
Is there clear entry/exit to the property?
Is there parking available?
Is there mobile phone coverage?
Are there any firearms/weapons on the property?
Is there hoarding on the property?
Is the property in a high-risk area? i.e. at risk of natural disasters such as flooding/fire?
Are there any pets on the property?
Are there any other occupants needing consideration who will be present during sessions?
Are there any concerns about the client's safety in the community?
Are there any concerns about the safety of the practitioner visiting?
Does the client, or anyone who will be present at the appointment, have a PAST history of:
Does the client, or anyone who will be present at the appointment, have a CURRENT history of:
Please attach Behaviour Support Plan (if applicable)
Are any of the following services involved or likely to be involved?

Finishing Up