Service area

SOUTH AUSTRLIAWESTERN AUSTRALIA

PARTICIPANT DETAILS

Participant does not have contact details, please contact primary contact

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

Street Address *

Gender *

Other: *

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

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. *

Reason For Referral

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)

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")

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)

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

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

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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