Referral / Service Enquiry

If you are interested in receiving services from Veritable, or would like to make contact on behalf of a participant or client, please complete the form below. We will make contact with you within 10 working days. For your records, we will also send you a copy of the referral submitted below.

Information for referrers:

Referrals are reviewed fortnightly, and clients are placed on a waitlist
The waitlist ensures that Veritable can provide high quality services to clients, with caseload numbers carefully set to maintain the best service
Additional information may be requested by Veritable upon receipt of the referral (and if so, the client is not placed on the waitlist until the information is received from the referrer)
Referrals are prioritised based on date received, client needs, and risks to the client and others
Relevant factors taken into account include the client’s age, support situation, any contact with the justice system (or risk of contact), and frequency and severity of issues arising
Ensuring sufficient detail in referrals enables an informed assessment of the referral and priority on the waitlist – more information will assist the client’s needs to be properly considered

If you would prefer to email the referral and supporting documents, please use the Veritable Referral Form v5

Veritable Referral / Service Enquiry Form

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Services requested *

Positive Behaviour Support
Support Coordination
Social Work Services
Other (please specify below)

Participant or client name *

First

Last

NDIS Participant number (if applicable)

Date of Birth (DD/MM/YYYY) *

NDIS Plan End Date (DD/MM/YYYY)

Primary Disability

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

(Include house phone if client is in supported accommodation)

Interpreter required *

Yes
No
Unsure

If yes or unsure, please identify language

NDIS Plan type (if applicable)

NDIA (Agency) Managed
Self Managed
Plan Managed
Mixed for services requested

Plan Manager (if applicable)

Include name of plan management company and contact for invoicing

Reason for enquiry or referral *

Please provide sufficient detail to assess the referral. This includes detail about the current issues and concerns, relevant background, brief description of any behaviours of concern, frequency and severity of any behaviours of concern.

NDIS Plan goals *

Please provide the participant's current NDIS Goals to ensure support services align with goals

Guardian or representative name

First

Last

Guardian or representative email

Guardian or representative phone number

Do you have consent from the participant/client and their guardian (if applicable) for this referral? *

Your Name (the Referrer) *

First

Last

Your Organisation

Your Relationship to the Participant

Your Email *

Who should be contacted to discuss the first appointment with the participant? (Name and contact details)

Veritable will make contact to discuss this referral and how best to help the participant to have a safe and supported experience, prior to making contact with a new participant to the service.

Where would the participant like the service to take place?

Home / SIL residence
Day supports / School
Workplace
Veritable office
Other

Does the participant have current behaviours of concern?

If yes, a copy of any current or previously completed behaviour support plan will be requested prior to contact with the participant

Does the participant have any restrictive practices in place?

If yes, please describe

Does the participant have any impairments with communication?

If yes, please describe

What are the participant's usual living arrangements

Supported Independent Living (SIL) / Aged Care
Family residence / Own home
Hostel / Other temporary
Homeless / Itinerant
Other

Does the participant have any co-tenants at their usual living arrangements?

If yes, provide relevant details

Please describe any other known risks relevant to initial assessment and contact with a new participant

Captcha (Anti-Spam) *

Phone