Referral – TRUSTING HANDS DISABILITY SERVICES

TRUSTING HANDS DISABILITY SERVICES

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Contact Info

Find out all you need to know about us, what we do, the services we offer, and most importantly how we will work with you to meet your needs to the highest standards.

E-mail (For Enquiry):

[email protected]

E-mail (For Feedback and Complaint):

[email protected]

Phone:

1800 023 123

Address:

24 Thunder Circuit, Harrison ACT 2914.

Referral Form

Please complete this form to assist Trusting Hands Disability Services (THDS) with your referral.

Are you making this referral for yourself? *YesNo

If you are making this referral on behalf of a participant, has the participant consented to the referral to be made? *YesNo

Personal Details

Participant's Full Name *

Date Of Birth *

Gender *

Phone *

Mobile0 / 10

Address *

What is your current living status? *AloneWith ParentsHospital?Shared Group Home?Other

Please Specify *

Nature of diagnosis (please provide details of all diagnosis and disabilities) *

Does this person have a legal guardian? If yes, please provide details. *

Does the person have an NDIS Plan? *YesWaiting for PlanNo (Required Assistance)

NDIS Number *

Start Date *

End Date *

Next of Kin for Emergency Contact

Name *

Phone *0 / 10

Relationship *

Referrer's Detail

Name *

Email Address *

Organisation

Phone *0 / 10

Date of Referral *

Relationship *

Current Support Needs

What types of support are you seeking from THDS?

When would you like to start accessing support from THDS?

Additional Information

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Legal entity: Trusting Hands Disability Services Pty Ltd

ABN: 16 751 301 384

ACN: 649 239 270

NDIS Provider Registration Number: 431759269

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