National Disability Insurance Scheme (NDIS) referral.

For NDIS participants: plan managed, self managed, or NDIA managed.

Who is completing this form?

Participant Information

Participant's Full Name*

Participant's Date of Birth*

Participant's Gender

Participant's Phone*

Participant's Email*

Participant's Address

Used for billing purposes. If not provided we'll confirm at intake.

Services Requested

What services is the participant interested in?*

Clinical Information

Please send any relevant medical information to admin@healthsocietyco.com.au

Participant's Primary Diagnosis*

Reason for Referral*

Participant's Goals*

Relevant Medical History / Attached Reports

Other treating practitioners, previous therapy, surgical history. Note any attached reports.

Availability for Clinic Appointments*

Recommended Treatment Frequency*

Contact to Book the Appointment*

If someone other than the participant manages their clinic bookings (e.g. carer, support coordinator, family member), please provide their name and number.

NDIS Details

NDIS Number*

Plan Dates (start – end)*

Available Funding ($)*

Funding Management Type*

Plan Manager Details

Name, organisation, phone, and email of the plan manager who will approve invoices. Required when plan managed.

Referring Practitioner

Practitioner's Full Name*

Role / Profession*

Practice / Organisation

Provider Number

Referrer's Phone*

Referrer's Email*

Additional Information

Cultural or Additional Information

How did you hear about Health Society Co.?*

Your information is transmitted securely and handled in accordance with our Privacy Policy.

By submitting this form you confirm you have the participant's consent to share their information with Health Society Co.