For Professionals

Refer a Participant

For support coordinators, local area coordinators, health professionals and other services. Complete as much detail as you can so we understand the participant’s needs before supports begin.

Before you send this referral

Where possible, email a copy of the participant’s current NDIS plan and goals to info@nexasupportcoordination.com.au.
Share only what is needed to assess and set up supports, consistent with the Privacy Act 1988 and the NDIS Practice Standards.
The participant, or their representative, should know what information is being shared and with whom before you submit.

Prefer a document? Open the participant referral form (PDF) and email it to us instead.

Referrer details

Person referring

Relationship to participant

Organisation

Your role

Contact number

Contact email address

Preferred start date for services

Participant details

Participant name

Date of birth

Postcode

Phone

Preferred communication method

Interpreter required?

expand_more

Interpreter language

NDIS plan and supports requested

NDIS number

How is the plan managed?

expand_more

Plan start date

Plan end date

Plan manager (if plan-managed)

Services requested

Support CoordinationSpecialist Support CoordinationPsychosocial Recovery CoachingOther / not sure

Supports requested and participant needs

Behaviours of concern, triggers or medical alerts

Other relevant information

Consent and privacy

The information on this form will be used only to assess and set up supports for the participant, and will be handled in line with the Privacy Act 1988 and the NDIS Act 2013. It will not be shared with other organisations except as needed to deliver these supports, unless required by law.

I confirm the participant (or their representative) is aware this referral is being made and consents to the information being shared for this purpose.