Referrals - Armoured Community Care Services

Thank you for referring to Armoured Community Care Services. Please complete this form to help us understand the support needs. We'll contact you within 2 business days.

REFERRAL SOURCE

Who is making this referral?

Referrer Information

Please input Referrer Information in this section

Name

First

Last

Your relationship to Participant

(e.g family, support coordinator, physiotherapist)

Referrer Organisation (if applicable)

Referrar's Phone Number

Referrer's Email

Referrer's Preffered Contact Method

Referrer's Best Time To Contact

Participant's Details

Name

First

Middle

Last

Date of Birth

Gender

Phone Number

Email

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Does the client have any communication needs we should know about?

If interpreter is required, which language?

Current Living Arrangement:

Is this an NDIS participant?

Yes- has NDIS plan
No - not on NDIs
Application in progress
Not sure

NDIS Number

Plan Management Type:

SERVICES REQUESTED

Which services are you interested in?*

Armoured Care Support Services

Assistance with Daily Personal Activities
Assistance with Household Tasks
Community Access and Participation
Transport Support and Assistance
Community Care (Non-NDIS)

Allied Health Services:

Other Supports

Support Coordination
Not Sure - need advice

When does participant need support to start?

Urgently (Within 1 week)
Within 2-4 weeks
Flexible timing
Just making enquiries

How often is support needed?

Estimated hours need

Input estimated hours needed by participant

Preferred days for support:

Preffered times:

EMERGENCY CONTACT

Emergency Contact Name:

Relationship

SUPPORT NEEDS AND GOALS ASSESSMENT

Please describe the client's primary disability, condition, or reason for support:

Primary Reason for Requesting Care

Please describe your care needs...

Participants main goals:

MEDICAL INFORMATION

Current Medical Conditions

Other Primary Number

Current Medications

Allergies

Document Uploads:

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please upload any relevant documents e.g, NDIS plans, Behavior support plan, Medical reports, Support needs assessment, other relevant information

CONSENT & PRIVACY

I consent to my data being stored...

Yes

"I understand my personal information will be used to provide care and will be kept confidential and secure in accordance with privacy laws."

I consent to contact

Yes

"I consent to being contacted by phone or email regarding my care needs."

Your Signature (type your full name)

Privacy Policy

"Your privacy is important to us. Read our privacy policy."

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admin@armouredcare.com.au