Referral – Candis Plans

Enquiries@candisplans.com.au

0404 717 031

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DISCLAIMER FOR NDIS REFERRALS:

Candis Plans is not a registered NDIS provider – we can provide support to NDIS participants with plan or self-managed funding. We can support participants to have their funding changed from agency (NDIS) managed to plan or self-managed funding (this is an easy and quick process and we can provide service whilst this is taking place).

Title:

Family Name:

Given Name/s:

Preferred Name:

DOB:

Diagnosis (List all):

Behaviours of concern? (Behaviour management plan?)

Health management plan? (Anaphylaxis, Asthma, Diabetes, Seizure, Falls)

Contact Details

Usual address:

Contact address (if different from above):

Contact phone numbers:

Choose preferred method of contact

Home: Work: Mobile: Email:

Emergency Contacts
Person 1

Name:

Address:

Phone:

Relationship to client:

Source of referral

Source of referral:

If not self-referred, has client given consent for referral?

Source of referral contact details:

Payment arrangements
NDIS PARTICIPANTS

NDIS Plan #:

NDIS Plan end date:

Funding model type (agency, plan or Self-managed):

Plan Managers details:

HOME CARE PACKAGE

Home Care #:

Billing details:

OTHER

Applicable reference number:

Billing details:

Interpreter required?

Yes No

Requested service

What service/s does the person require?

Yes No

How frequently is the support required i.e. hours/day or week?

Yes No

Does the person have preferred days or times for support?

Yes No

Does the person have any preferences for support workers – gender, communication, age, experience/qualifications?

Yes No

Detail what the shift should include.

Yes No

Does the person have any strengths/weaknesses/likes/dislikes that we should be aware of?

Yes No

OFFICE USE ONLY
Action required

Direct service provision

Service not available - waitlisted

Referral to third party/s

Information provision only – referral did not proceed

Ineligible for service – referral did not proceed

Other comment

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0404 717 031
Enquiries@candisplans.com.au

Working Hours

Business hours 9am-4.30pm weekday

Rostering changes 24×7 – 0404 717 031

Closed on pubic holidays except for essential support

Coming Soon

Client Intake Form

DISCLAIMER FOR NDIS REFERRALS:

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