Referral Form

Referral Form Updated

Participant Details

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

Additional Details

Emergency Contact

Participant Information

Does the participant have a secondary disability?
Does the participant require culturally appropriate information?
Does the participant have any allergies?

General Practitioner Details

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?
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)

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

Start Time
Finish Time

Risk Assessment

Risks
Does the participant or other residents of the home have a history of aggressive violent or sexual behaviour?
Do any neighbours have any relevant aggressive violent behaviours?
Does the participant have any 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?
Is the house inaccessible by a small, 2-wheel drive car?
Are any weapons located at the property? If so, are they safely locked away?
Are there issues with mobile reception at the property?

Referral Completed By

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

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.

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.