LumaWell Care Group Referral Form Client Details * First Name Last Name NDIS number Are you new to NDIS (National Disability Insurance Scheme)? Yes No How long have you been under NDIS? Please identify type of disability Are you from Aboriginal and/or Torres Strait Islander Descent? Yes No Date of Birth Select a date MM DD YYYY Address Home Phone Number (###) ### #### Mobile Number (###) ### #### Email Gender Male Female Transgender/Other Marital status Single Married De Facto Widowed Next of kin name and phone number Brief medical history (if any) GP's name and phone number Mobility status Independent Assist by One Assist by Two Using Frame Using Wheelchair Bed Board Plan dates (start and end) Plan management NDIA Managed Self-Managed Plan Managed If Plan Managed, please provide plan manager name, contact number and email Is the participant engaged with Public Trustee and Guardian? Yes No If yes, please provide name, contact number and email Sensory impairment (if applicable) Visual impairment Hearing impairment Sensory impairment Autism Spectrum Disorder Other If you checked 'Other', please specify Psychological/Special needs (if applicable) Living conditions Living alone Living with a partner Living with a family member Living in a group home Working status Disability pension Do not work Working Volunteer work Type of Package NDIS Private Care (No Package) Other (Please Specify) If you answered 'Other', please specify Type of Package Personal Care & Hygiene Home Services (cleaning, gardening & food preparation) Medication Administration Nurse Escort for Appointments Respite Care Palliative Care Rehabilitation & Injury Management Post Hospital Care Social Support Community Inclusion Transport Private Care Therapeutic Care Please list any preferred day/time suggestions for care Are you currently receiving any services? Yes No What date would you like your service to commence? MM DD YYYY What gender care worker would you prefer to have? Male Support Worker Female Support Worker Either Do you have any preferences for nursing staff with specific cultural background or language skills (in case Non-English-Speaking clients) Yes No What date would you like your service to end? MM DD YYYY Do you need staff to stay overnight? Yes No Sometimes Do you require transport to be provided as part of your care? Yes No Please list the goals that you would like to achieve Any additional comments Thank you!
