0422 509 869
hello@onestepcare.com.au

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About Us
- Policies
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Contact Us
- Complaint / Compliment & Testimonials
  / Feedback
- Join Our Team

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0422 509 869

Referral

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Is this Referral for*

Coordination of Supports

Psychosocial Services

Daily Life and Community Access

Coordination of Supports*

Level 1 - Support Connection

Level 2 - Support Coordination

Level 3 – Specialist Support Coordination

Psychosocial Services*

Psychosocial Recovery Coaches

Mental Health Support Worker

Daily Life and Community Access*

In-Home Support

Community Access

Participant Information

Full Name*

Date of Birth*

MM slash DD slash YYYY

Your Gender*

Are you of Aboriginal or Torres Strait Islander origin?*

Other Gender Describe here

Street*

Suburb*

State*

Postcode*

Email*

Phone*

Is an interpreter required?*

Yes

Please specify language:*

Primary diagnosis

Secondary diagnosis

How is the plan managed?*

NDIS Managed

Plan Manged

Self managed

Name of the plan manager/Company*

Email*

Name*

Email*

Emergency Contact Person

Name*

Email*

Phone*

Relationship to Participant*

Address*

List the participants NDIS goals

Do you want to list your NDIS goals?

Yes, now

No, later

Ndis Goals*

Ndis Goals

Budget Information for Level 1 - Support Connection

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for Level 2 - Support Coordination

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for Level 3 – Specialist Support Coordination

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for Psychosocial Recovery Coaches

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for Mental Health Support Worker

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for In-Home Support

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Budget Information for Community Access

Number of days*

Budget amount*

Plan start date*

MM slash DD slash YYYY

Plan end date*

MM slash DD slash YYYY

Total hours required

Describe how you want your supports to look like?

Alerts/Risk assessment

Is the house visible from the street?*

Yes

Is there a safe / close place to park?*

Yes

Does the property have adequate lighting inside and outside?*

Yes

In the event of an emergency, is the property accessible for emergency vehicles from more than one direction?*

Yes

Are there any hazards/obstructions entering the house?*

Yes

Is the home a smoking environment?*

Yes

Are there any weapons or firearms on the property?*

Yes

Are there any known infections/ illnesses in the house?*

Yes

Are there any animals with open access to the front of the property or inside the house?*

Yes

Are there any manual handling (e.g. lifting) or other safety concerns?*

Yes

Is there mobile phone coverage in the area?*

Yes

Is there evidence that anyone at home may be under the influence of alcohol or drugs?*

Yes

Does anyone that may be present at the time of the home visit have a history of aggression, violent, disturbed, inappropriate, or offensive behaviour?*

Yes

Is there anything specific we should be aware of? e.g. safety alerts, legal issues, police involvement, behaviors of concern, health related concerns etc.*

Yes

Specify alert*

Who else is involved with the care of this participant (e.g. Local Area Coordinator, Service Coordinator Family, Carer, Occupational Therapist, Psychologist, Speech Pathologist, other services)?

Name

Relationship to participant

Contact details

Please list any existing reports that are available (e.g. Behavior Support Plan, Health Reports, NDIS Plan)

Type of report

Name and position of person completing the report

Date of the report

Attach Reports

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 15 MB.

Please specify who is completing this Referral Form?*

Please provide your details*

Mobile*

Additional information

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Name*

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About Us

One Step Care is a Registered NDIS provider, known for providing support services to participants with disability, and supporting them towards their mental health across Melbourne and Geelong.

ABN – 78661519464
NDIS Provider Number – 4050144783

Contact Details

PO BOX 2105 Footscray VIC 3011
0422 509 869
hello@onestepcare.com.au

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Our Services

Coordination of Supports
Psychosocial Services
Daily Life and Community Access

About Us
Referral
Contact Us
Join our Team

Acknowledgment

We are an ally of the LGBTQIA+ community. We acknowledge the Traditional Owners and Custodians of the lands on which we live and work and pay our respects to Elders past, present, and emerging.

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