Disability Services Referral | The Benevolent Society

If you know someone with disability who would benefit from assistance or would like to refer yourself, please complete this referral form.

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About you - The Referrer

My Relationship with the person needing disability support* - required

First name* - required

Last name* - required

Organisation name

Phone Number* - required

Email* - required

I have consent from the client to make this referral* - required

Y N

Client Funding Details

Client funding details

NDIS plan start date

NDIS plan end date

How is funding managed?

NDIA managed Self managed Plan managed Other

Plan manager/funding details

Background information

Please share any extra information (ie. individual circumstances, urgency, etc)

Attach a document here

For Occupational Therapy Referrals

As you chose Occupational Therapy above from the support options list, please select at least one of the options below.

Please select at least one of the options below* - required

Basic equipment prescription - Assessment of Low-mid cost/complexity items e.g., chair raisers, toilet/showering aids, bed sticks, high-back chairs, Complex equipment prescription - Complex posture positioningReplaceSemiColon Wheelchair prescription and complex seating, high-cost equipment, powered equipment, hoists. Includes reports or supporting letters Please select one of the options below Sensory assessment and intervention - Assessment of sensory processing and provide therapy recommendations for accommodating sensory needs and intervention strategies. Including reports Paediatric assessment and intervention - Assessment of child development and provide therapy recommendations and intervention strategies, including reports AND/OR Assessment of, and intervention in (daily routines) toileting, dressing, sleep, hygiene, etc., including reports AND/OR Fine and gross motor skill development Home assessment and non-structural home modifications - Assessment of home access, safe mobilisation and function within the home, possible equipment or basic-moderate (under level 3) home modifications Unsure (add more detail below)

If you selected Unsure, add your details here

For Speech Therapy referrals

As you chose Speech Therapy above from the support options list, please select at least one of the options below.

Please select at least one of the options below* - required

Communication assessment of speech, language and literacy - Assessment and provide therapy recommendations and intervention strategies. Including reports Communication assessment and intervention - Develop expressive and/or receptive communication skills AND/OR Implementation of Alternative Communication strategies AND/OR Social skill development / play skills AAC assessment and intervention using AAC - Completing assessment, AAC trials, report writing and equipment prescription AND/OR Intervention to support developing skills in using AAC Eating and drinking / Feeding Disorder assessment and mealtime management plan development - Conduct mealtime assessment, write swallowing assessment reports and adult mealtime management plan AND/OR Intervention for children with swallowing difficulties and/or are fussy eaters Unsure - add more details below.

If you selected Unsure, add your details here

Carer/ Support/ Guardian

Carer/ Support/ Guardian Information

Does the client have a care/ support person?* - required

No Yes, The Referrer Yes, Specify below

Communications Contact

Communications Contact Information

Who is the best communications contact?* - required

The Referrer The Client The Carer, specified above None, specify another person below

Mandatory field(s) marked with *