Refer Now | Everyday Independence

Your Details

Please enter your information below.

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Organisation Name*

Organisation State or Territory*

Relationship to person being referred*

How did you hear about Everyday Independence?*

Please add participant's external client ID/ reference ID*

Person Seeking Therapy Details

Please enter your client’s information below.

First Name*

Last Name*

Preferred Contact Number

To receive courtesy appointment reminders, please enter a mobile phone number.

Mobile

Landline

Mobile Number

Landline Number

Note: Include area code for landline numbers.

Email Address

Date of birth*

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

Do they identify as Aboriginal or Torres Strait Islander?

Residential Address

Street Address*

Suburb*

State or Territory*

Postcode*

Services

While we ask what type of therapy your client requires, Everyday Independence brings a range of complementary team skills to plan and deliver therapy that’s tailored to make the most of their NDIS funding.
Families with children aged up to nine will be supported by an early childhood key worker.

Services required*

Occupational Therapy

Speech Pathology

Physiotherapy

Early Childhood Supports

Positive Behaviour

Functional Assessment

Habit Coach

To access Positive Behaviour service, the NDIS plan must have funding under Improved Relationships.

Do you have Improved Relationships funding on their NDIS plan?*

An Early Childhood Key Worker will consult and lead the therapy team (Occupational Therapists, Speech Pathologists, Physiotherapists, Educators and Social Workers) based on your child’s need. You do not need to select any other services. Our ECS services are not available with private health or Medicare funding. In Step 5 please select the funding that applies to your child.

Habit Coaching is offered as part of our therapy package, please ensure another service is selected also.

Tell us about their goals and how we can support them:*

Do they have a practitioner preference?

Male

Female

No preference

Family or Support Contact Details

Please enter your client’s family or support contact details, if relevant.

Parent/Guardian?

Parent/Guardian

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Support Coordinator?

Support Coordinator

Use my details

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Plan Nominee?

Plan Nominee

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Who should receive communications relating to updates to appointments, service delivery and waitlists?

Please note the communication recipient must be +18 yrs of age.

Use my details

Use details of person seeking therapy

Use parent details

Use Support Coordinator details above.

Use Plan Nominee details above.

First Name*

Last Name*

Phone Number*

Note: Include area code for landline numbers.

Email*

Non-verbal

Please tick if non-verbal

Relationship to the person seeking therapy*

Funding Details

Please enter your client’s plan details.

Does the person have an NDIS Plan?*

Yes

Awaiting Plan Approval

Please call us to find out how your client can access our services, if they don’t have a NDIS Plan.

NDIS Number*

Funding Type*

Plan Managed – Organisation name*

Plan Managed – Email*

NDIS Plan Start Date

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

NDIS Plan End Date

DD slash MM slash YYYY

Date format must be dd/mm/yyyy

NDIS Plan

Accepted file types: pdf, jpg, png, Max. file size: 5 MB.

Please attach a copy of NDIS plan here. Otherwise, you can email this through to referral@everydayind.com.au

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What to Expect

Our Therapies

Work with Us

Client Referral

Your Details

Person Seeking Therapy Details

Residential Address

Services

Family or Support Contact Details

Who should receive communications relating to updates to appointments, service delivery and waitlists?

Funding Details