Referral Form Demo

Referral Form

Referral Form Updated

Team Leaders

Each Participant that receives Community Access & Capacity Building Supports is assigned to a Team Leader. Our Team Leaders are an important part of our support structure at Empowered Community Services. Each of our Team Leaders has first-hand experience in the field of Disability Support Work and uses their valuable experience to guide our Support Workers. Team Leaders are able to provide support to our Participants and are able to ensure that their supports remain person-centred and that each Participant is continually given the choice and control over their support plan. Team Leaders will be charged under Non-Face to Face Supports from the most relevant line item. This will be written in a Participants Service Agreement as Team Leader Assistance.

Participant Details

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

Additional Details

Emergency Contact

Emergency contact (Please list a family member or stakeholder where possible)

Participant Information

Does the participant have a secondary disability?
Does the participant require culturally appropriate information?
Does the participant have any allergies?
Does the participant have a pre existing health condition?

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
Add Remove

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?
Do they have any history of self-harm, or suicidal ideation, or have they made suicidal attempts in the past?

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 your image to share on their social media accounts, website & advertisements? *
Do you consent to Empowered Community Services offering you other services that relate to your goals? *
Do you agree to be given information about other services related to your goals and support needs whilst at Empowered Community Services? *