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evina connect
Registered Provider Number: 4050168924
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Social Work
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Psychosocial Recovery Coaching
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Referral
Evina Connect Referral Form
Which service would you like to access:
Which service would you like to access:
*
Social Work (NDIS referral)
Support Coordination
Specialist Support Coordination
Psycho-social Recovery Coaching
Social Work (Private or Aged Care referral)
Are you completing this form on behalf of someone else?
Yes
No
If yes, name & contact of person completing this form
Participant details
Participant First name
*
Participant Last name
*
Phone
*
Email
*
Birthday
*
Day
Month
Month
Year
Address
*
NDIS number
*
Gender
Disability
*
Preferred mode of communication:
*
Phone
Email
Is the participant Aboriginal or Torres Strait Islander?
*
Yes
No
Is the participant culturally and linguistically diverse?
*
Yes
No
If yes, place of birth?
Do they require an interpreter?
*
Yes
No
Emergency Contact
Emergency Contact Name
*
Emergency Contact email address
*
Emergency Contact phone number
*
Emergency Contact relationship to participant
*
Preferred person to contact about this referral
*
Decision making capacity and authority
Does the participant have decision making capacity and authority:
Yes
No
Do you have a Plan Nominee or Representative?
*
Yes
No
Representative relationship to participant (if applicable):
Guardian
Power of Attorney
Other
Who signs documentation?
Representative name (if applicable)
Representative email address
Representative phone number
Referrer Information
Referrer name
Organisation (if applicable)
Phone number
Email address
Relationship to participant
Family
Support Worker
Service Provider
Friend
Other
How did you hear about Evina Connect?
*
Key Information for Service Delivery
Preference for male or female worker:
Male
Female
No preference
Session preferences:
*
In person
Telehealth
Combination of telehealth and in person
At school
At home
In the community
Unsure
Has the participant had a Support Coordinator or Recovery Coach previously?
Yes
No
Brief description of the participant's support needs (ie finding housing, connect with allied health, support workers, community access, assistive technology)
What would you like to focus on in your sessions (if know):
NDIS Goals
Relevant background information
Trauma
Family violence
Loss/grief
Child protection involvement
Mental health concerns
Disability
Plan dates
*
Plan Management Type for this service
*
Self Managed
Plan Managed
Agency Managed
Plan Managers name (if Plan Managed)
Plan Managers email address for invoicing (if Plan Managed)
Total funding available for Support Coordination/Recovery Coaching?
*
Total funding available for Social Work?
Are there funding periods in the plan for this service?
Yes
No
If yes, please outline the funding periods for this service:
Funding Type
*
Home care package
Support at home
Private paying
Who will be responsible for paying invoices?
*
Name and email for invoice:
*
Current Support Services Onboard (if applicable)
Is the participant currently receiving any psychosocial support?
Yes
No
Safety and Risk Considerations
Known Risks?
*
Yes
No
If yes, please explain
Is anyone at your / the participants property, known to be aggressive or violent?
*
Yes
No
If yes, please explain
Does anyone at your/the participants property have a criminal history?
*
Yes
No
If yes, please explain
Does the participants have a behavioural support plan in place? Are there any behaviours of concern?
*
Yes
No
If yes, please explain
Are there any pets at the premises?
*
Yes
No
If yes, please explain
NDIS Plan
Upload File
Submit
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