Skip to content
If you require an interpreter for our website, please contact TIS National at:
131 450
Home
About
Support Staff
Office Staff
Governance
Partnerships & Sponsorships
Volunteers & Student Placements
Support Services
Individual Supports
Respite
Programs
Expressions of Interest
School Holidays
Special Events
Term Programs
News & Resources
NDIS Pricing
News
Pulse Radio
Events
Referrals
Contact
Memberships
Careers
Menu
Home
About
Support Staff
Office Staff
Governance
Partnerships & Sponsorships
Volunteers & Student Placements
Support Services
Individual Supports
Respite
Programs
Expressions of Interest
School Holidays
Special Events
Term Programs
News & Resources
NDIS Pricing
News
Pulse Radio
Events
Referrals
Contact
Memberships
Careers
Get Involved
Referrals
Submit your referral below:
This referral form can be completed by parents & representatives or other professionals. As part of our intake process, we will be in contact to arrange an appointment to conduct this either in person or over the phone. This is an important part of our participant-driven support, and aren't able to begin supports until this has been undertaken.
Participant Details
First Name
(Required)
Last Name
(Required)
Gender
(Required)
Male
Female
Other
Other (Please Specify)
(Required)
Date of Birth
(Required)
Day
Month
Year
Any Preferred Pronouns
Phone Number
(Required)
Email Address
(Required)
Address
Street Address
City
State
Postcode
Interpreter Required?
(Required)
Yes
No
Does the participant have NDIS funding?
(Required)
Yes
No
Other
Other (Please Specify)
Participant Representative Details (If Applicable)
First Name
Last Name
Phone Number
Email Address
Address
Street Address
City
State
Postcode
What Is Your Preferred Contact Method?
(Required)
Email
Phone Call
Text Message
Any Of The Above
NDIS Funding
Does the participant have a nominated support coordinator?
(Required)
Yes
No
Other
Other (Please Specify)
(Required)
Support Coordinator Contact Details (If Applicable)
Plan
(Required)
Plan Managed
Self Managed
Agency Managed
Plan Manager Name
(Required)
NDIS Number
(Required)
Available / Remaining Funding
Please specify funding category if known
Plan Start Date
(Required)
Day
Month
Year
Plan Review Date
(Required)
Day
Month
Year
Participant NDIS Goals
Referrer Details (Person Making the Referral)
Are you the Participant's Representative Previously Identified Above?
(Required)
Yes
No
First Name
(Required)
Last Name
(Required)
Organisation
Role
Phone Number
(Required)
Email Address
(Required)
Reason for Referral
Referred For
(Required)
In Home Support
Individual Community Access
Domestic Assistance
Term Programs
Other Social Programs
School Holiday Programs
Overnight Respite / Accommodation
Any other services required
Programs interested in:
Junior Cooking Group
Gamer's Group
Junior Gamer's Group
Teen Cooking Group
Music Workshop
Juniors Art & Craft Workshop
Lego Club
Teen Boys Social Group
Tween Art Group
Teen Girl's Social Group
Junior Social Saturdays
Teen Social Saturdays
Tween Social Saturdays
Young Adults Group
Sports Clinic
Teen Art & Craft
Adult Social Day Program
Adult Art & Craft Workshop
Adult Cooking Group
Parent Support Group
Neurodivergent Adult Social Group
Sibling Support/Social Group
Independent Living Skills Program
LGBTGQIA+ Group
Homeschooler's Activity Day
Kids Afterschool Care
Alternative School Days (Juniors)
Alternative School Days (Teens)
Adults Gamer's Group
This includes current or upcoming programs, more programs in development can be found via our Programs Expressions of Interest Form
Does the participant have any disabilities or conditions?
(Required)
Intellectual
Cognitive
Physical
Autism (ASD)
PDA (Pathological Demand Avoidance/Pervasive Drive for Autonomy)
Generalised Anxiety Disorder
PTSD or C-PTSD
Other Anxiety Disorders/Conditions
OCD
Tourette's
Cerebral Palsy
ADHD
ODD
Mental Health
Eating Disorder
Acquired Brain Injury
Genetic Disorders
Down Syndrome/Other Chromosomal
Psychosocial
Other
None
More Information
(Required)
Any other relevant information
Does the participant demonstrate any of the following behaviours on a regular basis?
(Required)
Absconding
Excessive Swearing
Hitting Others
Hittings Oneself
Kicking Others
Self Harm
Property Destruction
Inappropriate Questions and/or repetitive questioning
Shouting
Headbutting
Other
None of the above
Other (Please Specify)
(Required)
Does the participant have any of the following health conditions?
Asthma
Anaphylaxis
Epilepsy
Diabetes
Allergies
How Did You Hear About Us?
(Required)
Social Media
Google
Brochures
Word of Mouth
Events
Support Co-Ordinator/Other Professionals
Newspaper Articles
AmAble Staff Member
Existing Participants
Clickability
The A List
Local Businesses
Other
Any Details
Other (Please Specify)
(Required)
Would You Like To Be Added To Our Mailing List?
(Required)
Yes
No
Already Subscribed
Do You Have Any Preferences For Days or Times For An Intake Appointment?
Please allow for up to an hour for this appointment.
Preferred Contact for Intake Appointment?
if not the participant's representative
File Upload
Drop files here or
Select files
Max. file size: 16 MB.
(Please attach a copy of the current NDIS plan and any other relevant documents/plans if possible)