Affirm Care Referral Form

Affirm Care Referral Form

Please complete this form if you would like to receive services from Affirm Care.
Section 1: About You

Tell us about who you are. We want to get to know you.
Client's Name

First NameLast Name
Preferred name
Gender
Date of birth

DayMonthYear
Date
Place of birth
NDIS number
Your Address & Contact Details
House Number & Street
Suburb
Postcode
Phone Number
Please enter a valid phone number.
Can we call you?

I don't use a phone.YesNo
Your Email
example@example.com
Can we email you?

I don't use email.YesNo
Please describe your culture.

AboriginalTorres Strait IslanderNot Aboriginal or Torres Strait IslanderOther
What is your preferred language?
Do you require an interpreter?

YesNo
Who do you live with?

No one. I live independently.My family.Supported accommodationOther
Is there anything about your culture, values or beliefs you want Affirm Care to know?

YesNo
If yes, please tell us more
Section 2: About Your Referrer

Tell us about who is referring you. We will contact them to find out more.
Who is completing this referral?

It's me! I'm referring myself.Someone else. Please complete details below.I consent to this referral.
Referrer's first name
Referrer's last name
Relationship to me
Organisation name (if a formal support)
Referrer's Email
example@example.com
Phone number
Section 3: Supporting Your Decisions

Tell us about how you make decisions & what support you need. We want you to have the information you need to make the choices you want.
How do you make decisions?

I make my own decisions. I don't need any help.My family or a support help me make decisions (no formal guardian)I have a formal guardian who make decisions for me.
Supporter's Name (if applicable)
Supporter's phone number
Supporter's Email
example@example.com
Guardian's name (if applicable)
Phone number
Guardian's Email
example@example.com
How do you need information given to you?

Written, plain English.Easy Read (words & pictures)Written, language other than English.Verbal, English.Verbal, by an interpreter.Verbal, simple English.Key Word SignAuslanOther
Section 4: Your Support Needs

Tell us what you would like us to help you with.
What services would you like to receive?

Supported Independent LivingCommunity SupportIn-home SupportNursingSpecialist Disability Accommodation (SDA)
Primary Diagnosis & Disability
How does your disability impact your life?
What would you like to achieve? What are your goals?
What days would you like our services?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
What time of day?

MorningAfternoonEveningNight
Section 5: Funding Details

If you would like to use NDIS funding to access our support, we require these details.
Plan start date

DayMonthYear
Date
Plan end date

DayMonthYear
Date
How is your NDIS funding managed?

Self-managedNDIA managedPlan managed
Plan Manager's Name
Plan Manager's Phone Number
Plan Manager's Email
example@example.com
What funding budget do you want to use?

Core Supports - Daily ActivitiesCore Supports - Assistance with Social & Community ParticipationSupport CoordinationImproved Daily Living (therapy)Improved Relationships
Are you happy to give us a copy of your NDIS plan?

Yes, I will share the whole plan.No.I'm not sureN/AI will only share some sections. See next question.
Which parts of your plan are you happy to share?

About MeMy GoalsMy SupportsCore Supports BudgetCapacity Building Supports Budget
Who will sign the service agreement?

I willMy emergency contactMy guardian
Who is responsible for paying invoices?

I willN/AMy emergency contactMy plan manager
Section 6: Emergency Contact

Tell us who we should contact if you need help.

This might be the person who is most important to you.
Emergency Contact Name

First nameLast name
Email
example@example.com
Phone number
Their relationship to me
I want them to be sent all communication & reports from Affirm Care

YesNo
Section 7: Home Safety

We want to make sure that your home is safe for our staff.
Is there parking?

YesNo
Do you have animals?

YesNo
Is there mobile phone coverage?

YesNo
Do you or anyone else smoke in the home?

YesNo
Is there a clear exit from your home?

YesNo
Are there any guns or weapons in the home?

YesNo
Do you have a history of drug use or alcohol dependence?

YesNo
Do you or anyone else use illicit drugs (incl. alcohol dependence) in the home?

YesNo
Anything else we should know?
Your name
Referrer's name
Your signature so we know you are aware of this referral

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Referrer's signature

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Date

DayMonthYear
Date
Date

DayMonthYear
Date
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