NDIS Participant Referral Form

Welcome! This form is designed to help new participants apply to receive support from WGS. By filling it out, you’re taking the first step toward becoming part of our community, and we’re excited to learn more about how we can support you.

Please complete the form with as much detail as possible so that we can understand your needs and guide you through the next steps. If you have any questions or need assistance at any point, please don’t hesitate to reach out, we’re here to make the process as easy and welcoming as possible.

Participant Information

First Name

Last Name

Gender

Date of Birth

Address

Phone Number

Email Address

NDIS Number

Primary Disability

Reason for Referral

Other services involved

Plan Manager Details (if applicable)

First Name

Last Name

Organisation

Contact Number

Plan Start Date

Plan End Date

Legal Guardian (if applicable)

Full Name

Phone Number

Support Coordinator (if applicable)

Full Name

Phone Number

Emergency Contact

First Name

Last Name

Relationship

Contact Number

Referring Person/Organisation

First Name

Last Name

Organisation (if applicable)

Phone Number

Service Request

Type of Service Requested

Frequency of Service

Duration of Service

Additional Information (e.g. funding allocated to service requested)

Consent to Share Information

The information provided in this form will be kept confidential and will only be used for the purpose of providing the requested service. Your consent will be obtained prior to any sharing of your information with any other parties. We adhere to all privacy regulations and policies to ensure the security of your personal information.

I hereby give my consent to share the information provided in this form to With Grace Support for the purpose of accessing the requested services.

Full Name

Date