SERVICE AREA

SOUTH AUSTRLIAWESTERN AUSTRALIA

Is this referral for a NDIS Participant? *

YesNo

Person Making Referral *

ClientClient Representative (parent/guardian/Nominee)Other

CLIENT DETAILS

Participant does not have contact details, please contact primary contact

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Gender *

Other: *

Street Address *

City *

State *

Postcode *

Primary Contact

Full Name *

Relationship to the participant *

Contact Number *

Contact email *

Client Representative Details (If Applicable)

First Name *

Last Name *

Phone Number *

Email *

Street Address *

City *

State *

Postcode *

NDIS Details

Plan *

Plan Managed Agency Managed

Please note* We no longer accept Self Managed Participants

Is this client on PACE *

YesNoUnsure what that means?

Plan Manager Agency/Name *

Plan Manager Agency Email *

NDIS Number *

Primary Diagnosis *

Plan Start Date *

Plan Review Date *

Client Goals (As stated in the NDIS plan) *

Referrer Details (Person Making the Referral)

First Name *

Last Name *

Agency

Role *

Email Address *

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 DETAILS

Does the participant have funding period schedule on PACE? *

YesNo

Please provide short description of funding period schedule *

Please bill under *

09_006_0106_6_3 - Life Transition Planning Incl. Mentoring PeerSupport And Indiv Skill Develop15_043_0128_1_3 - Assessment Recommendation Therapy or Training - Counsellor

Please make sure the participant has this funding line item in there plan.

Where Would the Client need to be billed from *

Capacity BuildingCore - Assistance with Daily Life

What is the available/remaining funding? *

Would you like to add an additional service?

Mental Health MentoringKitchen Crew

Would you like to add kitchen crew as a service offering?

How many Support worker Appointments does the participant need per week? *We have a minimum of 3 hours per appointment of Face to Face support. (Billed under Core – Assistance with Daily Life or Capacity Building)

how many hours of support is needed per appointment? *You can request different amount of time for each session. Example, 3 hours for one appointment of the week and 4 hours in the second appointment of the week.

How Many sessions of Mental health counselling does the Participant Need *Each session has a minimum of 1 hour of Face to Face support. (billed from 15_043_0128_1_3 | $156.16 Per Hour)

How Many sessions of Mental health Social Work does the Participant need? *Each session has a minimum of 1 hour of Face to Face support. (billed from 15_621_0128_1_3 | $193.99 Per Hour)

What amount of support are you wanting? *Each session is a minimum of an hour at $77 per hour

What type of session? *

Face to face - in Office (SA only)Virtual (Australia-wide)Face to Face - Home visit (NDIS clients only)

How many sessions per week does the participant need? *We have a minimum of 4 hour Face to Face support per session.

How long do you need each session? *We have a minimum of 4 hour face to face support per session.

How often would you like each session? *Each session is a minimum of 4 hours

How long would you like each session? *Most common session lengths are 1.5 hours but we have a minimum of a 1 hour session. Our pricing is $193.99/hr.

How many Virtual Reality Therapy sessions would you like? or how much funding can you allocate? *Please let us know how many sessions you would like to have. Please either state how many sessions you would like or we you can state how much funding is available for VRTA and we can work out how many sessions for you. (an example of this would be - "We can allocate $3,500 for sessions")

What is your Dungeons and Dragons Experience Level?

Experience Level *

Beginner: I’ve never played before but I’m curious to learn!Novice: I’ve played a little and know the basics, but I’m still learning.Intermediate: I’ve played a few campaigns and understand the rules well.Expert: I’ve played lots of games, and I might even want to help others learn!

Days and times for availibility for Dungeons & Dragons

Reason For Referral *

Do you give BCOGNITIVE consent to contact existing providers and inquire about funding and best support practise? *

KNOWN RISKS - Please provide details regarding any known risks *

Who do you want us to send the service agreement to? *Please include who you would like the service agreement sent to, to get signed

How would you like the service agreement and consent forms to be sent to sign *

Via email as PDF Via Digital signing platform

If you choose to use a digital signing platform, You will be sent a link through your email to sign digitally (no Printing needed)

How would you like us to send the Intake form? *

Via email as PDF - to be printed and filled out Via email as a Link - to be filled and submitted onlineComplete on first session

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

Browse

File Upload (Where appropriate - please attach a copy of any risk assessments or behavior support plans)

Browse

Would you like us to contact you before we send off the service agreement to be signed

How did you hear about us

Any Additional Comments