Referral | Empowered Community Services

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Our Commitment to Reconciliation

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Reimagine Resources

Empowered RAP Artwork

Community Access

Support Coordination

Holidays (Respite)

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Specialist Support Coordination

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Empowered Holidays

Careers at Empowered

Holiday Support Worker

Coordinator of Supports

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Referral Form

Referral Form Updated

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Click here to go to our Easy to Access Referral Form

Participant Details

First Name *

Last Name *

NDIS Number *

Phone Number

Email Address

Plan Start Date

Plan End Date

Date of Birth *

Gender *

Male

Female

Other

Does the participant identify as Aboriginal or Torres Strait Islander? *

Yes

No

Prefer not to answer

Participant Address

Would the participant like to work with a Support Worker who identifies as Aboriginal or Torres Strait Islander?

Yes

No

Does the Participant identify within the LGBTQI community?

Yes

No

Prefer not to answer

What pronoun does this participant use?

The participants preferred method of communication is

Preferred Mail Address

Preferred Contact Email

Participant is currently *

NDIS Managed

Self Managed

Plan Managed

OtherOther

Additional Details

Plan Manager Name

Invoices to be sent to

Invoices to be sent to

Emergency Contact

Name *

Relationship *

Email Address

Phone Number *

Address

Participant Information

What is the participants primary disability? *

Does the participant have a secondary disability?

Yes

No

Please list secondary disability

Best way to communicate

Does the participant require culturally appropriate information?

Yes

No

Please describe the participants requirements

Reason for referral

Previous & current services

Details of any medications

Does the participant have any allergies?

Yes

No

Please clearly list each allergy and the reaction the participant may have

Please list any dietary requirements

General Practitioner Details

Name of GP

GP Phone Number

GP Address

Does the participant require medication to be administered during support hours? *

Yes

No

Does the participant have a companion card? *

Yes

No

Services Requested by the Participant

Community Access

Short Term Accomodation (holidays)

Group Activities

Support Coordination

Specialist Support Coordination

Has the participant consented to this referral?

Yes

No

Would the participant like any course of action to be taken in the event of no response to a scheduled visit? (For example, not answering the door)

Yes

No

What course of action should Empowered take in the event of a no response? (For example, call participants emergency contact)

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*

Support Schedule

Text

Day of Support *

Start Time

Finish Time

Details *

Risk Assessment

Risks

Alcohol/Drugs

Traffic

Flammables

Sharps

Does the participant or other residents of the home have a history of aggressive violent or sexual behaviour?

Yes

No

Please provide details of history of aggressive, violet or sexual behaviour.

Do any neighbours have any relevant aggressive violent behaviours?

Yes

No

Please provide details of any neighbour's' aggressive violent behaviours.

Does the participant have any alcohol, gambling or substance abuse issues?

Yes

No

Please provide details of alcohol, gambling or substance abuse issues

Are there any pets at the property that may pose a risk of injuring a support worker, or escaping when a support worker enters the property?

Yes

No

Please provide details of any pets at the property that may pose a risk of injuring a support worker, or escaping when a support worker enters the property

Is the house inaccessible by a small, 2-wheel drive car?

Yes

No

Please provide details about access

Are any weapons located at the property? If so, are they safely locked away?

Yes

No

Please provide details of weapons

Are there issues with mobile reception at the property?

Yes

No

Please provide details of mobile reception issues

Other Risks

Referral Completed By

Name

Relationship

Address

Contact

NDIS Goals *

Introduction to the Participant *

Other Information

Upload additional information such as participants NDIS plan

Maximum upload size: 516MB

How did you hear about us? *

Facebook

Instagram

Word of Mouth

Friend

Google

NDIS Local Area Co-ordinator

Support Coordinator

Other Disability Services

Disability Expo

Do you give consent for Empowered Community Services to use my image to share on their social media accounts, website & advertisements? *

I do

I do not

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.

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(02) 4054 9286
admin@empoweredcs.com
Suite 102/286 Main Road
Cardiff, NSW, 2285

(02) 4054 9286
admin@empoweredcs.com
Suite 102/286 Main Road
Cardiff, NSW, 2285

0404 787 154
admin@empoweredcs.com
Suite 102/286 Main Road
Cardiff, NSW, 2285

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© Copyright 2020 Empowered Community Services | Terms and Conditions

Empowered Community Services Pty Ltd
ACN: 634 541 076 | NDIS Provider Number: 4050060444

Current Capacity

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0 Hours

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Specialist Support Coordination

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School Leavers Employment Program

0 Participants

Make a Referral

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

Make a Referral

Referral Form

Referral Form

Participant Details

First Name *

Last Name *

NDIS Number

Phone Number

Email Address

Plan Start Date

Plan End Date

Date of Birth *

Gender *

Male

Female

Other

Does the participant identify as Aboriginal or Torres Strait Islander? *

Yes

No

Participant Address

Would the participant like to work with a Support Worker who identifies as Aboriginal or Torres Strait Islander?

Yes

The participants preferred method of communication is

Participant is currently;

NDIS Managed

Self Managed

Plan Managed

OtherOther

Preferred Mail Address

Preferred Contact Email

Additional Details

Plan Manager Name

Invoices to be sent to

Invoices to be sent to

Primary Contact

Name *

Relationship *

Email Address *

Phone Number *

Address

Participant Information

What is the participants primary disability? *

Does the participant have a secondary disability?

Yes

Please list secondary disability

Diagnosis

Best way to communicate

Reason for referral

Previous & current services

Details of any medications

Does the participant have any allergies?

Yes

No

Please clearly list each allergy and the reaction the participant may have

Please list any dietary requirements

Name of GP

GP Phone Number

GP Address

Does the participant require medication to be administered during support hours?

Yes

No

Does the participant have a companion card?

Yes

No

Services Requested by the Participant

Community Access

Short Term Accomodation (holidays)

Group Activities

Support Coordination

Specialist Support Coordination

Has the participant consented to this referral?

Yes

No

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

Monday Start

Monday Finish

Details

Tuesday

Tuesday

Tuesday Start

Tuesday Finish

Details

Wednesday

Wednesday

Wednesday Start

Wednesday Finish

Details

Thursday

Thursday

Thursday Start

Thursday Finish

Details

Friday

Friday

Friday Start

Friday Finish

Details

Saturday

Saturday

Saturday Start

Saturday Finish

Details

Sunday

Sunday

Sunday Start

Sunday Finish

Details

Referral Completed By

Name

Relationship

Address

Contact

NDIS Goals

Introduction to the Participant

Risks

Alcohol/Drugs

Traffic

Flammables

Sharps

Other Risks

Other Information

Do you give consent for Empowered Community Services to use my image to share on their social media accounts, website & advertisements? *

I do

I do not

How did you hear about us? *

Facebook

Instagram

Word of Mouth

Friend

Google

NDIS Local Area Co-ordinator

Support Coordinator

Other Disability Services

Disability Expo

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.

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