Life Care Services Australia
Please complete ALL the fields below (referrals may be delayed if information is incomplete.)
If the information is not available, please write N/A or (-). Please complete the form below and our team will be in touch with you shortly.
Full Name*
Date of Birth*
Email address*
Language-- Select anyone --EnglishOther
Phone*
Mobile*
Suburb/ Town*
State*
Postcode*
Marital status-- Select anyone --SingleIn a relationshipMarriedWidowedDivorcedSeparatedOther
Gender*-- Select anyone --MaleFemaleOther
If other, please describe*
Address*
Communication-- Select anyone --SigningGestureBody LanguageVerbalNon-VerbalOther
Interpreter-- Select anyone --YesNo
Preferred Contact Method-- Select anyone --PhoneText MessageEmailFace to FaceOther (e.g. online / telehealth)
Ethnicity-- Select anyone --CulturalLinguistically
Indigenous-- Select anyone --AboriginalAboriginal & Torres Strait IslanderNot stated / Inadequately describedTorres Strait IslanderNo
Living Arrangement-- Select anyone --AloneFamilySupport AccommodationTorres Strait IslanderOther
Sexuality-- Select anyone --Straight / HeterosexualLesbian / Gay / HomosexualBisexualOther
Occupation*
Source of Income-- Select anyone --PensionCarer AllowanceDisability PersonOther
Mode of Payment-- Select anyone --Credit CardDebit CardBankOther
Contact Category-- Select anyone --FamilySupport PersonParticipant RepresentativeNDIS Plan NomineeEmergency ContactPower of AttorneyPower of Attorney (Financial)Power of Attorney (Medical)State TrusteeFinancial ManagerCorrespondence ContactGeneral PractitionerCarerOther
NDIS Authorized-- Select anyone --ParentGuardianEnduring Power of AttorneyAppointed by the NDIAOther
NDIA*
NDIS Plan From Date*
NDIS Plan To Date*
Managed By-- Select anyone --ParentSelf-ManagedNDIA-ManagedPlan Managed
Plan Manager Name*
Plan Manager Address*
Plan Manager Phone*
Plan Manager Mobile*
Attach NDIS Plan (or relevant section of the plan)
Support Level Ratio-- Select anyone --YesNo
About Participant (Self)*
Likes*
Dislikes*
NDIS Budget*
Funding Category*
Private Funds*
Support Line Items*
Other Budget*
Details*
Support Level Ratio-- Select anyone --1:11:21:3Other
Support Level Type-- Select anyone --HourlyWeeklyMonthlyYearlyCasualOther
NDIS Approved Hours*
Services-- Select anyone --Community ParticipationLife Skills DevelopmentInnovative Community ParticipationAssist Travel Transport & Community AccessHigh Intensity Daily Personal ActivitiesHousehold TasksGroup Centre ActivitiesDaily Tasks Shared LivingAssistance With Personal CareCommunity Nursing CareSupport CoordinationRespite CareAllied Health Therapy ServicesBehavioral Support ServicesOther
Day-- Select anyone --Monday
From Time*
To Time*
Whole Day-- Select anyone --YesNo
Active Night / Sleepover-- Select anyone --YesNo
Other Information*
Day-- Select anyone --Tuesday
Day-- Select anyone --Wednesday
Day-- Select anyone --Thursday
Day-- Select anyone --Friday
Day-- Select anyone --Saturday
Day-- Select anyone --Sunday
Primary Diagnosis*
Secondary Diagnosis*
Other Diagnosis*
Medical Conditions*
Allergies*
Special Request / Other Requirement*
Documentations Requirements (Behavior Plans/ Assessments, Safety Plan, Mental Health Review Risk Assessment, any other relevant documents)
Risk Assessment (for our staff)-- Select anyone --Animals on PremisesHistory of ViolenceWeapons/Firearms on PremisesBehaviours of Concern or Other
Staff Gender Preference-- Select anyone --MaleFemaleNo Preference
Relationship to Participant*-- Select an answer --Case ManagerFamily MemberLegal GuardianParticipantPrimary CarerSupport CoordinatorOther
