Referral Form | Evina Connect

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evina connect

Registered NDIS Provider

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Registered Provider Number: 4050168924

Evina Connect Referral Form

Which service would you like to access:

Which service would you like to access:*

Social Work (NDIS referral)

Positive Behavioural Specialist

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 of person completing this form:

If yes, contact number or email of person completing this form:

Preferred person to contact about this referral*

Participant details

Participant first name*

Participant last name*

Preferred name

Phone*

Email*

Birthday*

Day

Month

Year

Address*

NDIS number*

Clients AC 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*

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

Would remote (no face to face) support be suitable for this SC service? *

Session preferences:*

In person

Telehealth

Combination of telehealth and in person

At school

At home

In the community

Unsure

Is this the participant's first NDIS plan?

Yes

No

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)

Funding amount available/remaining for Support Coordination/Recovery Coaching?*

Total amount available for Social Work?

What is you Aged Care package/ Support at Home funding level? *

Do they have an Advance Care Directive or power of attorney in place? *

Total funding amount available/remaining for Positive Behavioural Specialist Support?*

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 or Aged Care Plan

evina connect

0492 915 380 - Kate

0422 699 169 - Lauren

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hello@evinaconnect.com.au

evina connect acknowledges the traditional owners of this land. We pay our respects to the people, their rich culture and the elders past and present.

NDIS Provider Number: 4050168924

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