Question 1
Are you aged between 7 and 65?
Yes. Go to the next question.

No. I have a child aged under 7. Find out more about Help for children under 7.

No. I'm over 65. You must be under 65 to access the NDIS. You may be able to access other supports. Find out about NDIS and Aged Care.
Question 1
Question 2
Do you live in Australia and have Australian residency?
Yes. I live in Australia and I am an Australian citizen or have a Permanent or Special Category Visa. Go to the next question.

No. You may be able to access other supports.The NDIS is only available to:
  • People who live in Australia
  • Australian citizens
  • Permanent Visa holders
  • Protected Special Category Visa holders.
  • Question 2
    Question 3
    Do you usually need support from a person because of a permanent and significant disability?
    Yes. You may be eligible. Find out how to apply.

    No. Go to the next question.
    Question 3
    Question 4
    Do you use special equipment because of a permanent and significant disability?
    Yes. You may be eligible. Find out how to apply.

    No. Go to the next question.
    Question 4
    Question 5
    Do you need some supports now to reduce your future needs?
    Yes. You may be eligible. Find out how to apply.

    No. The NDIS may not be the best way to support you. You may be able to access other supports.
    Question 5

    Current Capacity

    WE HAVE CAPACITY !

    Community Access & Capacity Building

    0 Hours

    Support Coordination

    0 Participants

    Specialist Support Coordination

    0 Participants

    School Leavers Employment Program

    0 Participants

    Current Capacity

    WE HAVE CAPACITY !

    Community Access & Capacity Building

    0 Hours

    Support Coordination

    0 Participants

    Specialist Support Coordination

    0 Participants

    School Leavers Employment Program

    0 Participants

    Referral Form

    Referral Form

    Participant Details

    Gender *
    Does the participant identify as Aboriginal or Torres Strait Islander? *
    Participant is currently;
    Additional Details

    Primary Contact

    Participant Information

    Does the participant have a secondary disability?
    Does the participant have any allergies?
    Does the participant require medication to be administered during support hours?
    Does the participant have a companion card?
    Services Requested by the Participant
    Has the participant consented to this referral?

    Please note, Empowered has a minimum shift length of four hours for all new participants.
    *Participants who require less than a four support will be subject to approval and will depend on the total number of hours of support required per week*

    Preferred Times

    Day

    Start

    End

    Details

    Monday
    Monday Start
    Monday Finish
    Tuesday
    Tuesday Start
    Tuesday Finish
    Wednesday
    Wednesday Start
    Wednesday Finish
    Thursday
    Thursday Start
    Thursday Finish
    Friday
    Friday Start
    Friday Finish
    Saturday
    Saturday Start
    Saturday Finish
    Sunday
    Sunday Start
    Sunday Finish

    Referral Completed By

    Risks
    Do you give consent for Empowered Community Services to use my image to share on their social media accounts, website & advertisements? *
    How did you hear about us? *
    Upload additional information such as participants NDIS plan
    Maximum upload size: 516MB

    Team Leaders

    We encourage all participants to be assigned a Team Leader from Empowered. Our Team Leaders can help with tracking participant goals, developing strategies to assist with support, communicate strategies with staff, and develop reports as requested. If you do not wish to be allocated a Team Leader please notify our administration staff.