NDIS Referrals - Walk Different

NDIS Plan Type

Funding Source*

Self Managed NDIS Client
Plan Managed NDIS Client
GP Referral
Private Billing

Do you have a preferred psychologist?

Select All
Adrian Comensoli
Martin Daly
Sarah Gellatley
Mollie Snelling
Michelle Wills

Do you have a preferred location?

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Cronulla
Dapto
Wonoona
Wollongong
Shellharbour

Plan Manager Details

Name

First Last

Phone

Practice/Company Name

Address

Street Address Address Line 2 City State Postcode

Client Details

Name*

First Last

Phone*

Date of Birth (DD/MM/YYYY)*

Email

NDIS Screening

1. You are the client's:

Your Name*

First Last

Your Phone Number*

Email*

2. Has the client's permission been obtained to make this referral?*

3. What is the client's diagnosis and severity of their condition?

4. Has the client been previously treated for this condition by a psychiatrist/psychologist?

Yes
No

5. If answered yes to question 4, what was the duration, frequency and outcome of this treatment, if any?

6. Please list anyone else involved in the client's treatment (GP, psychiatrist, OT etc) If so, how often do they see them?

7. What are the specific goals that the client wishes to address in counselling sessions?

8. How comfortable is the participant in being outdoors and interacting in social settings?

9. How likely is the participant to stay with the clinician during the session?

10. Describe the client's communication skills:

11. Does the client engage in any violent behaviour (swearing, hitting etc) towards themselves or others, and if so, please describe:

12. Does the client have meltdowns and if so, please describe the nature and any known triggers for the client's meltdowns:

13. How frequent, if any, are the client's meltdowns?

14. What support have the parents/guardians/carers sought to identify and manage any behavioural issues?

15. Please outline why you/the client has chosen an outdoor service over an indoor one?

Has there been any behavioural managed plans developed for the participant, and if so please upload here or bring to the first session:

Drop files here or

Comments

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Walk Different NDIS Portal

NDIS Plan Type

Plan Manager Details

Client Details

NDIS Screening

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