Date of referral:	Referred by:
CLIENT DETAILS
Title:	☐ Mr ☐ Mrs ☐ Ms ☐ Miss ☐ Other ____________
Client Name:	Gender:	☐ Male ☐ Female ☐ Non-Binary ☐Other_________ (please specify)
Date of birth:	_ _ / _ _ / _ _ _ _	Culture & Religion:
Residential address
Contact details	Mobile: Home: Email: If the contact person isn’t participant, please specify:
Identifies as:	☐ Aboriginal ☐Torres Strait Islander ☐Other
Health & Disability:
Preferred communication method:	Can client use DocuSign? (electronic signing)
Does the client have the ability to sign?	If no, please provide reason:
Who does the client nominate to sign on their behalf?
Emergency contact:	Name: Phone: Mobile: Home: Email: Relationship to participant:
Client Interests:	Criminal/Justice System history: (MUST ANSWER)
NDIS DETAILS
NDIS Number:	NDIS Plan Dates: Funding Periods:	☐ Yes ☐ 3 monthly ☐ Other
How to Claim:	☐ NDIA Managed	☐ Self-Managed Email:	☐ Plan Managed Plan manager:
LAC/Local Area Coordinator details:	COS/Coordinator of Supports details:
Copy of NDIS plan: If no, please provide reason	Client’s goals as per NDIS plan:

Additional Information

Please send this FULLY completed referral form to reception@clean-as.com.au

NDIS SERVICES required
Domestic Assistance: Frequency & hours?	Clients are to provide all cleaning products and equipment.
Yard maintenance: Frequency & hours?
Community Access: Frequency & hours?
Meal Prep: Frequency & hours?
Personal Care: (Central West area) Frequency & hours?

Our team will respond to you accordingly.