Make a referral

Intake & Referral Form

Complete the form below to refer a participant to Kevria. Once submitted, our team will be in touch to prepare a Service Agreement. Required fields are marked with an asterisk (*) — everything else is optional but helps us get started faster.

Referral Details

Tell us who is making this referral.

Referral date

Referrer name *

Relationship to participant

Referrer phone

Referrer email *

How long have you known the participant?

How did you hear about us?

If other, please specify

Participant Details

Participant name *

Date of birth

Participant address

Guardian / Nominee

If the participant has a guardian, plan nominee, or primary carer.

Guardian / nominee name

Phone

Support Coordinator

Support coordinator name

Phone

NDIS Plan Details

NDIS number

Plan start date

Plan end date

Support category / budget

Remaining NDIS funding

Plan manager — company

Plan manager — contact name

Plan manager — phone

Plan manager — email

About the Participant

Aboriginal or Torres Strait Islander

Language spoken at home

Preferred communication

Communication comments

Supports Requested

Behaviour support

Accommodation / SIL

Community access

Other supports

Hours of support required

Level of support

Current service provider (if any)

Include travel / kilometres?

Include public holidays?

Behaviour Support History

Previous behaviour intervention?

Previous BSP organisation

Type of previous intervention

Current Allied Health & Practitioners

List any allied health professionals currently involved.

Discipline 1

Organisation 1

Practitioner 1

Discipline 2

Organisation 2

Practitioner 2

Discipline 3

Organisation 3

Practitioner 3

Diagnoses

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosed by

Medications

Medication 1

Medication 2

Medication 3

Can the participant self-administer medications?

General Practitioner

GP name

GP practice

Support Schedule

Approximate hours of support required each day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Schedule notes

NDIS Service Line Items

Select the NDIS support items relevant to this referral.

Line item 1

Line item 2

Line item 3

Reason for Referral

Reason for referral *