NDISspringclean - Home Assist Community Services

Thank you for your referral, due to the shortage of supplies and as we approach Christmas, Home Assist will only be processing urgent inbound referrals. If your matter is non urgent, please submit your referal on or after the 3rd january 2023, there is a current wait time of 12 weeks for all non urgent matters.

NDIS Maintenance & Spring Cleans / Minor Mods Referral Form

To be completed for NDIS requests.

Form Reference Number 5

Name of Home Care Package Provider *

Name of Home Care Package Provider

Case Managers Details

Aged Care Number of Consumer

Title *

First Name *

Surname *

Preferred Name

Country of Birth

Language

Date of birth *

Street Address *

City

ZIP / Postal Code

Postal Address (if different)

City

ZIP / Postal Code

Phone Number *

Mobile

Email Address

Additional Contact Person

Relationship to Client

Phone

Mobile

Consent to act on behalf of recipient

Residency Type *

Owner / Landlord / Agency Name (if applicable) *

Owner / Landlord / Agency Postal Address *

Suburb and Postcode *

Phone *

Mobile

E-Mail *

Please Choose the Type of Referral *

Pre-approved amount up to $ *

NDIS Plan Type *

Support Coordinator Name *

Support Coordinator Organisation *

Phone *

Mobile

Email *

Plan Manager Name *

Plan Manager Organisation *

Postal Address

Suburb and Postcode

NDIS Number *

NDIS Package Start Date *

NDIS Package End Date *

NDIS Package Provider *

NDIS Package Contact Person *

Postal Address *

Suburb and Postcode *

Phone *

Mobile

E-Mail *

E-Mail Address for Quotes (if different from above)

E-Mail Address for Tax Invoices (if different from above)

Work Request 1 *

Instructions *

Would you like to referral this client for any additional work request/s?

Work Request 2

Instructions

Pre approved amount/hours

Line Item Number

Work Request 3

Instructions

Pre approved amount/hours

Line Item Number

Work Request 4

Instructions

Line Item Number

Pre approved amount/hours

Work Request 5

Instructions

Line Item Number

Pre approved amount/hours

All work requested has been discussed with and has the consent of the client or their carer *Yes

Name of Person Submitting Referral *

Phone Number of Person Submitting Referral *

File Upload *

No file chosen

For Uploads over 8MB, please use one of the free of charge file transfer services for example https://wetransfer.com/

All referrals and quoting will incur a cancellation fee of $55.00 should our office not be notified in writting 24 hours before the booking.

Please note that quoting for all NDIS works requires a service booking to be made and paid prior to your home visit.

Please send a copy of this form submission to

Submission Date *

Please do not fill in this field.

133 Adelaide Street Maryborough 07/4123 2234

07 4123 2234

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NDIS Maintenance & Spring Cleans / Minor Mods Referral Form

Call Us Now 07 4123 2234

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Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

07 4123 2234

Login

NDIS Maintenance & Spring Cleans / Minor Mods Referral Form

Call Us Now 07 4123 2234

Apply For Support

I need Help finding a form

Home Assist Community Services

- Work For Us -

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845 Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)

Non-Profit Organisation Established in 1999 - QBCC Builders Registration: 1109355 ABN: 82493405845
Home Assist Community Services 133 Adelaide Street Maryborough QLD4650 - Phone 07/4123 2234 Monday to Friday 9am until 3pm (message bank after hours)