Hello & Welcome

First Name (Legal) *

Last Name *

Date of Birth *

Preferred Name *

Pronouns (She/He/They/Ze) *

Where are you located?

Brisbane (QLD)Sydney (NSW)Melbourne (VIC)Other

Do you identify as?

Gay Lesbian BisexualPansexualNon-Binary Transgender Gender Diverse (Other)Queer Other

Do You Identify As First Nations? *

Phone Number *

Email Address

Street Address *

City *

State *

Postcode *

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Street Address

City

State

Postcode

NDIS Details

Plan *

Plan Managed Self Managed Agency Managed

Plan Manager Name (If Applicable) *

Plan Manager Agency (If Applicable) *

NDIS Number *

Plan Start Date

Plan Review Date

Referrer Details (Person Making the Referral)

First Name

Last Name

Agency

Role

Email Address

Phone Number

I have obtained consent from the participant to make this referral and provide Rainbow Inclusions with the participant's personal and medical details. *

Reason For Referral

Referred For *

Support Coordination Psychosocial Recovery CoachingSupport WorkersCapacity Building Support WorkersSocial Work CounsellingCommunity NursingOther

Listed Disabilities *

Details About Your Disabilities *

Restrictive Practice? *

Yes No

File Upload (Please attach a copy of the current NDIS plan if possible)

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Risk Assessment Private & Confidential

Are there any safety concerns we need to be aware of? *

Any occupants, visitors, pets that may pose a threat? *

Does anyone have a history of violence: physical, sexual, verbal aggression? *

Any substance abuse issues? *

Any AVO’s, criminal offences - anyone who may have an issue with the clinician visiting home? *

Any known weapons or firearms? *

Are any medications, controlled substances or drugs administered intravenous *

Do you or someone in your home carry airborne, contact or blood borne diseases? Example: (Tuberculosis, Polio, HIV, Hepatitis, HSV, MRSA?)

I understand that Rainbow Inclusions staff require a safe working environment. I have answered the Rainbow Inclusions risk assessment questions truthfully and/or to the best of my ability/knowledge. *

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