Referral – Unique Health Services

Your Details

Your Role *

Your Name *

Your Phone *

Your Company *

Your Position Title *

Participant’s Details

Participant’s Name *

Participant’s NDIS Number *

Date of Birth *

NDIS Plan Start Date *

NDIS Plan End Date *

Phone *

Gender *

Address Line 1 *

Address Line 2

City *

State / Province / Region *

Postal Code *

Country *

Participant Preferred Contact Name *

Participant Preferred Contact Phone Number *

Relationship to Participant *

Is the participant under guardianship? *

Who will be providing consent for this person? Name and contact number *

Preferred Language *

Will an interpreter be needed? *
YesNo

Primary Disability *

Reason for service request *

What service(s) does the participant require? *

Other (Please provide details)

Number of hours in participant’s plan *

NDIS goals *

Plan Manager First Name *

Who will manage payments? *

Are there any Worker Safety Concerns? *
History of Sexual ViolenceRisk of Use of WeaponsHistory of Interpersonal ViolenceEnvironmental RiskPhysical Aggression

Other Worker Safety Concerns

Plan Manager Email Address *

How did you hear about us?

Any additional information or comments?

I understand the estimated cost for the service requested on behalf of the participant. I consent to Unique Health Services up to the limit provided. If there is any change to this estimated cost, Unique Health Services provide a written Service Funding Approval document for review and approval from relevant parties.

Consent and payments

Your Details

Participant’s Details

Services

Pages

Opening Hours