Laurence Care
0480 316 452
info@laurencecareptyltd.com.au
41 Antares Parade, Kalkallo Vic 3064
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Home
About Us
Services
Forensic and Mental Health Supports
Positive Behaviour Support
Supported Independent Living
Community Nursing
Community participation
Specialist Support Coordination
Cleaning and Gardening
FAQ
Referral
Contact Us
Home
About Us
Services
Forensic and Mental Health Supports
Positive Behaviour Support
Supported Independent Living
Community Nursing
Community participation
Specialist Support Coordination
Cleaning and Gardening
FAQ
Referral
Contact Us
Book An Appointment
Home
About Us
Services
Forensic and Mental Health Supports
Positive Behaviour Support
Supported Independent Living
Community Nursing
Community participation
Specialist Support Coordination
Cleaning and Gardening
FAQ
Referral
Contact Us
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Referral
REFERRAL
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FULL NAME
DATE OF BIRTH
GENDER
PARTICIPANT PHONE NUMBER
PARTICIPANT EMAIL ADDRESS
PARTICIPANT NDIS NUMBER
HOME ADDRESS
DOES THE PARTICIPANT HAVE A LEGAL GUARDIAN / NOMINEE?
PARTICIPANT COUNTRY OF BIRTH
DOES THE LISTED PARTICIPANT IDENTIFY AS AN ABORIGINAL OR TORRES STRAIT ISLANDER?
NUMBER OF HOURS REQUESTED FOR SERVICE:
PARTICIPANT'S RELEVANT CONDITIONS / DISABILITY (PLEASE LIST):
FORENSIC AND MENTAL HEALTH SUPPORTS (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
MENTAL HEALTH SUPPORT
EMOTIONAL REGULATION SUPPORT
RISK ASSESSMENT SUPPORT
BEHAVIOUR MONITORING
PSYCHOSOCIAL SUPPORT
COMMUNITY ACCESS SUPPORT
OTHER
POSITIVE BEHAVIOUR SUPPORT (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
BEHAVIOUR ASSESSMENT
BEHAVIOUR SUPPORT PLAN
RESTRICTIVE PRACTICE SUPPORT
EMOTIONAL BEHAVIOUR SUPPORT
SKILL DEVELOPMENT
FAMILY/CARER SUPPORT
OTHER
SUPPORTED INDEPENDENT LIVING (SIL) (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
PERSONAL CARE ASSISTANCE
DAILY LIVING SUPPORT
MEDICATION ASSISTANCE
MEAL PREPARATION
OVERNIGHT SUPPORT
SHARED LIVING SUPPORT
COMMUNITY ACCESS
OTHER
COMMUNITY NURSING (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
MEDICATION MANAGEMENT
WOUND CARE
DIABETES SUPPORT
CATHETER CARE
PEG FEEDING SUPPORT
HEALTH MONITORING
CLINICAL CARE SUPPORT
OTHER
COMMUNITY PARTICIPATION (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
SOCIAL ACTIVITIES
GROUP ACTIVITIES
COMMUNITY ACCESS
SKILL BUILDING
TRANSPORT ASSISTANCE
RECREATIONAL ACTIVITIES
APPOINTMENT ASSISTANCE
OTHER
SPECIALIST SUPPORT COORDINATION (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
CRISIS SUPPORT
HOUSING SUPPORT
SERVICE COORDINATION
NDIS PLAN SUPPORT
COMPLEX CASE MANAGEMENT
ADVOCACY SUPPORT
RISK MANAGEMENT
OTHER
CLEANING AND GARDENING (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
GENERAL HOUSE CLEANING
DEEP CLEANING
LAUNDRY ASSISTANCE
LAWN MOWING
GARDEN MAINTENANCE
RUBBISH REMOVAL
HOME SAFETY CLEANING
OTHER
ADDITIONAL INFORMATION REQUIRED (PLEASE SELECT THE SERVICES YOU WOULD LIKE TO ACCESS)
MOBILITY SUPPORT REQUIRED
BEHAVIOURAL CONCERNS
MEDICAL CONDITIONS
COMMUNICATION SUPPORT REQUIRED
ALLERGIES OR RISKS
CULTURAL OR LANGUAGE PREFERENCES
PREFERRED CONSULTATION TYPE(S)
IN CLINIC
IN HOME SERVICE
COMMUNITY
TELEHEALTH
PARTICIPANT'S NDIS PLAN TYPE
NDIA MANAGED
PLAN MANAGED
SELF / NOMINEE MANAGED
EXTRA INFORMATION THAT MAY ASSIST WITH PREPARATION FOR INITIAL APPOINTMENT:
REFERRER NAME
REFERRER CONTACT NUMBER
REFERRER EMAIL ADDRESS
RELATIONSHIP TO PARTICIPANT
CONSENT
I CONFIRM THAT THE INFORMATION PROVIDED IS ACCURATE AND CONSENT HAS BEEN OBTAINED FOR THIS REFERRAL.
Submit
Area We Serve
Victoria
