IPC Health NDIS For Children - Make A Referral

The following must apply before submitting this form:

Child is between 3 years 6 months - 12 years old
Child has an active NDIS Plan (i.e., NDIS plan is ready and available)
Child's NDIS plan is self or plan-managed
Child lives within Hobson's Bay or Wyndham catchment areas

Acknowledgement *

I acknowledge that the above information is true for this referral

Please note that, given current staffing capacity, sessions are currently being delivered on Tuesdays.

Child Details

First Name *

Last Name *

Date of Birth *

Gender *

Pronouns *

He/HimShe/HerThey/ThemOther

Primary language spoken by child *

Is an interpreter required? *

YesNo

Please note that we are unable to provide interpreters for client's who are self or plan-managed.

If Other, please state language below:

Street Address *

Postcode *

City

Is the child attending school/kinder? *

YesNoNot sure

What is the name of the school/kinder? *

Child Parent/Guardian Details

First Name *

Last Name *

Phone Number *

Email

Street AddressPlease complete if different from child's address

City

Postcode

NDIS Plan Details

Plan *

Self-Managed Plan-Managed

NDIS Number *

Plan Start Date *

Plan Review Date *

Do you have an electronic copy of child's NDIS plan? *

YesNo

Most Recent NDIS Plan

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While it’s not required, sharing your NDIS plan can help us understand goals and support needs better. This can also make the intake process faster and ensure we set up the right services for you and your family.

If you cannot upload child's NDIS plan to this form, please send it to:

alliedhealth.ndis@ipchealth.com.au

While it’s not required, sharing the NDIS plan helps us understand goals and support needs better. This can also make the intake process faster and imrpove the quality of the services we provide.

Please upload any previous reports here

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Previous reports, like allied health reports, can help us better understand your needs and plan the right support for your child.

Plan Management Details

Plan Manager Name *

Plan Manager Company Name *

Invoicing Email *

Invoices

Email Address To Send Invoices *

Referral Information

Relevant Medical History (e.g., diagnoses) *

Please outline child's NDIS goals as stated in their NDIS planPlease complete if you have chosen not to upload child's NDIS plan

Reason for Referral - What do you hope to achieve with IPC Health's help? *

Services Required

Disciplines (Select All Required) *

Speech PathologyOccupational TherapyPsychology

Speech Pathology Services Required

Building and maintaining connections with othersLanguage Articulation (speech sounds)Assistive Technology

Occupational Therapy Services Required

Fine Motor Skills (e.g., handwriting, grasping objects)Gross Motor Skills (e.g., coordination, balance)Sensory Processing (e.g., sensitivity to sounds, textures, movement)Activities of Daily Living (e.g., dressing, feeding, toileting)Attention

Psychology Services Required

Emotional Regulation (e.g., managing anger, frustration, sadness)Anxiety ManagementTrauma and Stress ManagementBuilding and maintaining connections with othersBehaviourParent/Carer Support and Training

Appointment Preferences

Location Preference

IPC Health Altona MeadowsHomeCommunity (e.g., childcare)

While we may not be able to accommodate all preferred locations, please let us know which are most convenient for your family to attend appointments.

Time Preference

Morning Afternoon

While we may not be able to accommodate all preferred times, please let us know which are most convenient for your family to attend appointments.

Additional Information Regarding Appointment Days and Times

Who will confirm appointments? *

Parent/Guardian (as stated above)Other

Name of person confirming appointments *

Phone Number *

Email *

How Did You Hear About Us?

Please tell us how you found out about our intervention service: *

Who Is Completing This Form?

We will reach out if we need any more information to help with the intake process and/or to move forward with the next steps.

First Name *

Last Name *

Agency

Role

Email Address *

Phone Number *

Are you completing this form on behalf of someone else? (e.g., parent/guardian) *

YesNo

Please acknowledge that this person has consented to being referred to IPC Health's NDIS for Children service by ticking this box. *

Today's Date *