Referral

Participant consent to referral: Has the participant agreed to this referral and to ZIMS Care Services contacting them?
YesNoUnable to confirm

If consent was provided by another person, record their name, relationship and legal authority

Disability, health conditions and relevant support needs

Address

Email

Does the participant speak English?

Preferred language and communication method/format

Communication aid, Easy Read or other accessibility support required?

Is an Interpreter Service required for the Interview?

Does the participant identify as Aboriginal and/or Torres Strait Islander?

If Yes, do they have a Case Worker or Support coordinator?

Does the participant want their case worker, support coordinator or chosen representative involved in planning supports?

Email Address

Does the participant have a legally appointed guardian, nominee or other authorised decision-maker relevant to these services?

Email Address

Does the Participant have an Advocate?

Email Address

Rights and information provided: The participant or authorised representative has been informed, in an accessible way, about privacy, rights, feedback and complaints, independent advocacy and how to contact the NDIS Quality and Safeguards Commission.

Reason for referral

Support type, frequency, urgency and requested start.

Examples: support coordination, counselling, psychosocial recovery coaching, skill development, personal care, household tasks or community access.

Expected start date of client support

Does the NDIS plan include transport funding for social & community participation?