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HoH/Deaf NDIS referral form

For NDIS participants who are Deaf or Hard of Hearing. This form captures communication preferences so we can make every appointment accessible. Please complete it with as much detail as possible — if you're unsure about any sections, leave them blank and we'll follow up.

Participant details

Tell us about the person being referred for support.

First name *

Last name *

Preferred name (optional)

Sex

Date of birth

Phone

Address line 1

Suburb / Town

State

Postcode

Communication & accessibility

Help us make every interaction accessible from the very first contact.

Preferred method of communication

SMS Email Video call / Auslan

Is an Auslan interpreter required for appointments?

Yes No Other

How should we organise the first visit?

Contact the participant directly No, contact another person (provide details below)

NDIS plan details

NDIS number

How is the plan managed?

Plan start date

Plan end date

Plan manager (name & contact, if plan-managed)

Upload a copy of the NDIS plan (recommended)PDF, Word or image. Max 8MB.

Support needs

Diagnosis / disability (as listed with NDIS)

Reason for referral / supports requested

Daily Personal Activities Community Participation Household Tasks Community Nursing Care High Intensity Support Travel & Transport

Home visit & access

Are there any potential risks for staff visiting the home?

Yes No

Referrer / coordinator details

The person completing this form. You can refer yourself, or on behalf of someone else.

Your name *

Your email *

Your phone

Provider / company (if applicable)

Upload a recent FCA / OT report (optional)

Any other relevant document (optional)