Contact Us

1Referrer

2Partner/Carer Information

3Client Information

4Risk Assessment

5Authorisation/Signature

Date of Referral(Required)

DD slash MM slash YYYY

Referring Organisation(Required)

Name of Referring Person(Required)

First Last

Referring Person's Phone Number(Required)

Referring Person's Email Address(Required)

Type of Support Requested

Support Coordination

Level 2

Level 3

Support Services

Support Worker

Therapy

Other

If Other, Please List

Partner/Carer Name

First Last

Partner/Carer Phone Number

Does Partner/Carer live with Client?

Yes

Client's Name(Required)

First Last

Client's Date Of Birth

DD slash MM slash YYYY

Client's Phone Number

Client's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Does this client have a legal guardian?(Required)

Yes

Please state the name of client's legal guardian(Required)

First Last

Legal guardian's phone number

NDIS Support - does this person currenty receive NDIS funding?(Required)

Yes

Do they have an identified disability diagnosis? (Please state what this is)

NDIS Number (if known)

Type of NDIS management

Self Managed

Plan Managed

Agency Name

Are they able to effectively communicate their wants and needs to others?(Required)

Yes

Please describe their specific communication needs

Reason for referral(Required)

Is the client pregnant?(Required)

Yes

Antenatal Clinic Name

GP Name

Specialist Obstetrician

Estimate date of baby's birth

DD slash MM slash YYYY

Current stage of pregnancy (weeks)

Please enter a number from 0 to 40.

Other services involved in Client's care

Has this referral been discussed with the client?(Required)

Yes

Please ensure referral is discussed and consent for referral.

Current Vulnerabilities

Has the Client experienced any of the following vulnerablities in the past or now?

Multiple disabilities/ high medical needs/ severe intellectual disability

Abuse or domestic violence

Housing difficulties

A history of trauma and neglect

Been involved in statutory care or involved with Child Protection services

Lack of supports or connection to a support network

A breakdown in the relationship with a significant other

Other

Please list other vulnerabilities

Risk Assessment

To the best of your knowledge, please provide a response for the following risk factors: (tick ‘Yes’ or ‘No’)

Has the participant ever exercised force, towards any person including a caregiver that caused or could have caused injury?(Required)

Yes

Does the participant have a diagnosed mental illness (including paranoia)?(Required)

Yes

Is the participant currently taking any mental health related medication?(Required)

Yes

Does the participant collect/hoard items in their room/house?(Required)

Yes

If so, do the collected items pose a potential fire risk?(Required)

Yes

Does the participant smoke?(Required)

Yes

Does the participant have a history with substance abuse (illicit drugs/alcohol)?(Required)

Yes

Does the participant currently engage in or have a history of self-injurious behaviours/self-harm?(Required)

Yes

Is the behaviour of the participant unpredictable or do they have challenging behaviours? (Please describe in comments below)(Required)

Yes

Is the participant likely to have access to weapons?(Required)

Yes

Comments regarding identified risks

Authorisation(Required)

I give my permission for my service provider organisation to release the information on this form to DMC Support. I understand this information will be used to coordinate my specific care needs during pregnancy and early parenting.

I agree to provide a copy of my NDIS Plan goals to DMC Support.

Signature of client or guardian(Required)

Print Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Enquire Online

Make a Referral

Type of Support Requested

Current Vulnerabilities

Risk Assessment