NDIS Referral

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Step 1 of 5

Participant details

Tell us about the person being referred. All fields marked * are required.

Personal information

First name *

Last name *

Date of birth *

Gender

Preferred language

Contact details

Phone *

Home address *

Living situation

Current living situation

Lives alone

With family

With carer

Supported accommodation

Other

Step 1 of 5

Step 2 of 5

NDIS Plan details

We need this to confirm funding before booking your first appointment.

Plan information

NDIS number *

Plan end date

Plan management type *

Primary disability / diagnosis

Diagnosis or condition *

Brief background (optional)

Step 3 of 5

Services requested

Select all that apply. You can request multiple disciplines — our team coordinates directly.

Which services are you requesting? *

Occupational Therapy

Physiotherapy

Podiatry

Dietetics

NDIS Reporting

Appointment preference

Preferred location

Clinic

Home visit

Community

School / workplace

No preference

Goals or priorities for support

Step 4 of 5

Contacts & safety

This helps us reach the right people and ensures the safety of our clinicians before visiting.

Referring person

Your name *

Relationship to participant *

Your phone *

Your email *

Emergency contact

Name

Relationship

Phone

Safety & access information

Any safety considerations for home/community visits?

Any other relevant information?

Step 5 of 5

Review & submit

Please confirm the details below before submitting. We will contact you the same day.

Consent & declaration

I confirm that the participant (or their authorised representative) has consented to this referral and the sharing of their information with The Empowerment Project.

I understand that The Empowerment Project will contact me to confirm funding and appointment details before any services commence.

I agree to The Empowerment Project's Privacy Policy.

Referral received.

Thank you — we have received your referral and will be in touch the same day to confirm funding and book your first appointment.

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Prefer to call?

We are happy
to help.

Call us and we will complete the referral with you over the phone — no forms, no fuss.

(02) XXXX XXXX

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