Referral Form - Coordination of Supports (CoS)

Firstchance predominantly supports children with a NDIS plan and parents of children who have their own NDIS plan.

Participant Details

Does the child/participant have a NDIS Plan? *

NDIS Number

How is the NDIS Plan managed? *

If you are Plan Managed, what is the name of your Plan Management company?

Current NDIS Plan start date

File Upload - Please attach a copy of the current NDIS plan if possible

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Child/Participant First Name *

Last Name *

Preferred name

Street Address (start typing your address in the blank field below. When you see your address appear, click it to select) *

Postcode *

Date of Birth *

Gender *

Primary Carer/Contact person for this referral

First Name *

Surname *

Street Address of Primary Carer/Contact Person (if different to participant address)

Phone number *

Email address *

Relationship to child/participant *

Date of Birth (helpful for referrals to other organsations)

Please provide the contact details of who to contact in case of an emergency

Use contact details above

Name

Phone number

Emergency contact relationship to child/participant

If any other family members have previously received, or are currently receiving, services from Firstchance please provide details so that we can do our best when assigning team members to services

Please complete this section if you are NOT** the primary carer of the child/participant

Relationship of person making this referral to the participant/child

First name

Last name

Phone Number

Email

Please confirm that if this referral is being made by a 3rd party that you have obtained consent from the participant to make the referral and provide Firstchance with the participant's personal and medical details.

Please be aware that if you are completing this form as a 3rd party on behalf of the family the family will receive a copy of your responses sumitted herewith.

About the Child/Participant

Primary Diagnosis *

Other information regarding diagnosis

Child/participant's strengths

Child/participant's challenges

File Upload - Please attach a copy of any reports or assessment from previous providers or specialists that tell us about the person's progress, diagnosis or developmental/behavioural concerns. Reports help us to make informed decisions about suitable pathways for support.

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Services requested

Coordination of Support Services *

For a child with a NDIS PlanFor a participant who is also the parent/carer of a child with a NDIS Plan

Do you currently have or previously had a Coordinator of Supports? *

Name of current/previous Coordinator of Supports (or company name)

Is your current Coordinator of Supports aware that you are considering changing Coordinator of Supports? (we won't share this information - this is to assist with transition planning)

Current services

Are there other professionals or community services currently involved in supporting the child/family/participant? *

YesNo

Name

Service provided (e.g. speech therapist, occupational therapist), Family Support

Additional Information

The following information will assist Firstchance to support you/your child and family in the best possible way.

Firstchance embrace culture and diversity, living our values of inclusion, respect, intergrity and commitment.

We believe all people deserve to be supported to be the best person they were born to be. We are all stronger when everyone is included in our community.

Is the participant/child of Aboriginal or Torres Strait Islander Origin *

Participant/child's Country of Birth *

Is the participant/child from a CALD (Culturally and Linguistically Diverse) background? *

What language is spoken at home? *

What is the participant/child's Cultural Background *

Are there any family customs, religious or cultural practices to be respected by Firstchance staff? *

Please provide details: *

Do any of the following situations apply to the child/participant:

Foster care/child in non-parental care (e.g. grandparents, kinship) *Child protection / DCJ*Parent/carer/participant has disability/health/mental health concerns Family/participant is isolated or without extended family supportSibling(s) with disability

* Please note that for applicants receiving Out Of Home Care, parental responsiblity details will need to be supplied.

Are there any court orders or restraints that impact on who can access a service while either parent/carer/partner is in attendance. eg. AVO? *

YesNo

Summary of Details *

Please note: If court orders are in place, please bring the original to your first visit.

Additional Information: Please add anything else you would like to share about the child/family/participant.

How did you hear about Firstchance? *

If "other" please provide details: *

Today's date *

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