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02 4604 1111, 04 8002 6953
enquiries@rhemahealthcare.com.au
Contact Us
Call us:
02 4604 1111
,
04 8002 6953
Email:
enquiries@rhemahealthcare.com.au
Home
About
Services
Continence Care for Adults
Continence Care for Children
High-Intensity Care Plans
Clinical Assessments
Training Programs
NDIS Support
Referral
Assessments Referral
Training Referral
News & Events
FAQ
Feedback
Contact Us
Assessment
Referral
Referral
Referral Form with PDF - 31 October 2024
Client/Participant Details
First Name
Last Name
NDIS Number
NDIS Plan Start Date
NDIS Plan End Date
Date Of Birth
Phone
Email
Address
NDIS Support Coordinator/Referee
Name
Organisation
Email
Phone
Email of Person Responsible for Signing the Service Agreement
Location of where supports are to be provided (Please tick options that apply)?
Home
School
Supported Living
Clinic
Workplace
Indigenous Status
Aboriginal but not Torres Strait Islander origin
Torres Strait Islander but not Aboriginal origin
Both Aboriginal and Torres Strait Islander origin
Neither Aboriginal nor Torres Strait Islander origin
Culturally and Linguistically Diverse
I am not sure or prefer not to say
Is the Participant under 18 or subject to a legal order?
Yes
No
Legal Guardian/Parent/Close Contact Name
Legal Guardian/Parent/Close Contact Phone
Legal Guardian/Parent/Close Email
Legal Guardian/Parent/Close Address
House Coordinator Name
House Coordinator Phone
Funding
NDIA
Self-Managed
Plan Managed
Plan Management Details
Plan Manager Organisation
Plan Manager Contact Person
Plan Manager Phone Number
Plan Manager Email
Reason For Referral
Clinical Nurse Assessment
Continence Assessment
Staff Training
Other
Additional Information
This referral has been discussed with the NDIS Participant/ Participants legal representative
Yes
No
Name of person completing the referral
Date of Referral
How did you hear about us
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