REFERRAL FORM

Fill in the form to share more details about what services you are after.

First Name: *

Last Name: *

Date of Birth *

Phone Number: *

Email Address: *

Street Address *

Suburb *

State *

Postcode *

Does the Participant have a representative or primary contact *

Representative/NomineePrimary contact (participant does not have all/some of their own contact details)None of the above (participant is the best person to contact)

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STOP! Before you proceed, please confirm you/the participant do not have any of the following:

Epilepsy
Seizure disorders
Eye disorders
Heart conditions
Pregnant
prone to severe migraines

If you do have any of the conditions listed above, please consult your doctor before proceeding; we will require a doctor's note stating you can proceed with services.

Do you have any of the conditions listed above *

YesNo

Please upload your doctors note *

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Client Representative Details/Primary Contact

Representative Name *

Relationship to the participant *

Best contact Number *

Email *

Address *

NDIS Details

Plan *

Plan ManagedAgency/NDIA ManagedSelf Managed

Plan Manager Agency *

NDIS Number *

Plan Start Date *

Plan End date *

Referrer Details

Person making the referral *

Participant (referring myself)Nominee/Primary contactOther

Name *

Relationship to Particpant *

Agency (if Applicable)

Contact email *

Direct Phone number *

I have obtained consent from the participant to make this referral and provide BCOGNITIVE with the participant's personal and medical details. *

Referral

Headset options

Headset Ownership Options *

Rental of Headset | Prices from $500/Quarter to $1800/QuarterPurchase of VR Headset | Prices from $599.99 to $2075.99 (one-off purchase)Rent-to-own of Headset | Prices From $149.99/Quarter to $518.99/Quarter

Rental Headset *

Meta Quest 3s | $500 Per QuarterMeta Quest 3 | $900 Per QuarterMeta Quest Pro | $1800 Per Quarter

Rental second Preference if initial choice is unavailible: *

Rent-to-own Headset *

Meta Quest 3S: $599.99 over 4 quarterly payments of $149.99Meta Quest 3: $959.99 over 4 quarterly payments of $239.99Meta Quest Pro: $2075.99 over 4 quarterly payments of $518.99

Rent-to-own second Preference if initial choice is unavailible: *

Looks like you chose to Purchase your Headset outright!

Please Head to https://lowcostat.com.au/collections/virtual-reality-assistive-technology?page=1

This information will also be emailed to you with your service agreement.

Once you have chosen your headset , use the LowCostAT NDIS Checkout in your cart.

You will then be taken to an NDIS checkout form, where you will:

1. Submit Your Request
Fill out the form on our website to begin the process.
2. LowCostAT will Handle the Paperwork
They will upload the invoice to the NDIA or liaise with your Plan Manager for approval.
3. Order Confirmation & Delivery
Once payment is approved, they will notify you and ship your product promptly to us, where we will get your headset set up with the required program. After this we will then post the selected headset to you, ready for your sessions.

Reason for referral/Relevant Medical Information you would like the therapist to know *

Attach relevant files

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If you have any information you would like the therapist to know Feel free to attach documents here

Who would you like us to send the service agreement to *

Send Via

Email - PDFDigital signing patform - SignEasy

If you would like us to send via Digital signing Platform, the Service agreement will be sent through to selected persons email for them to sign

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