Make a Referral – Komplete Disability

This referral form is not monitored for emergencies. If someone is in immediate danger, call Triple Zero 000.

Referrer Details

Full Name *

Organisation

Role / Position

Phone *

Email Address

Relationship to Participant

Participant Details

Participant Full Name *

Date of Birth

NDIS Number (optional)

Address / Suburb

Preferred Contact Method

Preferred Language

Interpreter Required?

Aboriginal and/or Torres Strait Islander Identity

This information is optional and only collected if the person wishes to share it.

Service Requested *

Support Coordination

Specialist Support Coordination

Behaviour Support

Allied Health / Therapeutic Supports

Community Nursing

Daily Living

Community Participation

Other

Other Service (please specify)

NDIS Plan Details

Plan Management Type

Support Urgency

Plan Start Date

Plan End Date

Relevant Funding Category

Reason for Referral

Current Needs

Goals

Risks or Safety Concerns

Current Providers Involved

Consent

* Participant and/or guardian consent has been obtained for this referral.

Consent to contact the participant or referrer about this referral.

* Consent to collect and securely store the referral information.

Consent to share relevant information with stakeholders if required for service delivery.

Fields marked * are required to submit this referral.

Upload Supporting Documents (Optional)

You may upload relevant documents such as NDIS plans, behaviour support plans, reports, risk assessments, or consent forms.

Click to upload or drag and drop files here

Allowed: PDF, DOC, DOCX, JPG, PNG - Maximum 10MB per file

Not monitored for emergencies. For emergencies, call 000.