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NDIS Referral

For support coordinators, participants and authorised representatives requesting cleaning, garden care or maintenance services.

Please have the participant’s contact details, NDIS number, date of birth, plan dates, funding arrangements and signing contact ready. Include an emergency contact. If something is not yet known, tell us what needs confirming.

We use this information to discuss availability and prepare a quote and service agreement. Rates, travel and the final service schedule will be confirmed with you. Submitting a referral does not confirm a booking or funding approval.

Only share information you are authorised to provide. Please do not send full NDIS plans, medical records or access codes through this form. Privacy policy.

Just have a question? Send a general enquiry. Referring an aged care client? Choose the aged care referral form.

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Provider registration number: 4-3LLM-1490
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NDIS Service Request

1. Referrer details

Use this form to request services and provide the details needed for a service agreement. Fields marked * are required.

2. Services requested

Choose one or more services. Only the questions relevant to your choices will appear.

Cleaning

Minimum 2 hours per visit.
Cleaning visits have a 2-hour minimum.
Tell us which rooms or tasks need particular attention.

Garden care

Our standard schedule is weekly in summer, fortnightly in spring and autumn, and monthly in winter. You can request an alternative for us to discuss.
Tell us the schedule you would prefer. We’ll discuss availability and agree on arrangements with you.

Maintenance

We’ll discuss materials, costs and payment arrangements before confirming the work.

3. Participant details

We use these details to prepare the service agreement.

DD/MM/YYYY.
Leave blank if the participant does not use a phone.
Optional.
Include street address, suburb, state and postcode.
DD/MM/YYYY. If awaiting confirmation, tell us here.
DD/MM/YYYY. Tell us if the plan has been extended or the date is awaiting confirmation.
Name, relationship, phone and email.
If none is available, write None available so we can discuss this.
Write N/A if no emergency contact is available.
Write N/A if no emergency contact is available.
Include relevant pets, access arrangements, product sensitivities or communication needs. Please do not include key codes or medical records.

4. Funding and invoicing

Provide the funding available for the services requested. It is fine to tell us if an amount or date needs confirmation.

Tell us which services are plan managed, self-managed or NDIA managed.
Optional. If a budget or spending limit has been provided for these services, include it here. Otherwise, leave blank and we can discuss it when preparing the agreement.
List each period’s start date, end date and amount available for these services. Leave blank if not yet known.
Name, organisation, phone and email, if applicable.

5. Agreement and consent

Tell us who will review and sign the service agreement.

Write Participant if signing for yourself, or describe the representative’s authority.
Name, relationship and email, with the participant’s permission.
We use these details to contact the people nominated and prepare a service agreement. Submitting this form does not confirm a booking, funding approval or a signed agreement.