Participant information
First name	Last name
DOB	Preferred pronouns
Address	Postcode
Phone	Email
NDIS number	Plan dates
Cultural Identity and Considerations	Identifies as Aboriginal Identifies as Torres Strait Islander Identifies as both Aboriginal and Torres Strait Islander Prefer not to say Other cultural identity (please specify): Are there any cultural considerations or supports required? If yes, please provide details:

Referrer details
Name	Date of referral
Relationship to client	Self Family member Guardian LAC/Planner Other
Email	Mobile
Description of services required/points of crises

Reason for referral
Service type	Level 2: Coordination of Supports	Funding available Plan	$
Level 3: Specialist Support Coordination	$
How is the support coordination funding managed	NDIA Managed Plan Managed Self Managed
Plan Manager details	Name of Plan Manager:	Email for Invoices:
Client overview (Please provide relevant historical, mental health, disability-related, and accommodation history, including diagnosis)
Any relevant risk-related information (including current or previous/current legal orders)
Key care team member’s contact details and roles

Please see attached documents for information regarding mental health and diagnosed disabilities.