Referrals NDIS Participant DetailsGender:FemaleMalePrefer not to sayAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweAlternative Contact (in case the NDIS participant or Support Co-ordinator is unreachable)NDIS Plan DatesStart DateEnd DateReferred DetailsPlease select this box if you are referring yourselfJob Title / Role:Support CoordinatorCase ManagerFamily MemberLocal Area CoordinatorOtherWho Is The Primary Contact For This Referral?ParticipantSupport CoordinatorFamily MemberOtherPrimary Disability / Health BackgroundWho Is The Primary Contact For This Referral?Occupational TherapyGroup/Centre ActivityParticipate CommunityInnov Community ParticipationHousehold TaskAccomodation/TenancyAssist-Travel/TransportAssist-Personal ActivitiesAssist-Life Stage, TransitionDesired OutcomeNDIS Funding Managed byAgency ManagedPlan ManagedSelf-managedIf Plan Managed, or Self Managed please provide detailsIs anyone at your/the clients property, known to be aggressive or violent?YesNoDoes anyone at your/the clients property have a criminal history?YesNoDoes the client have a positive behavioural support plan in place?YesNoIs there a history of drugs or alcohol misuse at the property?YesNoAre you aware of any firearms being stored at the property?YesNoAre you aware of any occupant having an infectious disease? (i.e chicken pox / Covid-19 / gastro, etc.)YesNoDo you have any pets at your premises?YesNoAre there any other factors we should be aware of?YesNoHow Did you hear about us?Word of MouthFacebookGoogleInstagramOtherSend Message We’re Here to Support You Contact Us Our Services Facebook-f Linkedin Quick Links Home About Us Contact Us Privacy Policy Service Support & Services Careers Referrals Feedback Resources & Downloads Get In Touch Oasisstudio@info.com (914) 937-6019 345 William St Port Chester, New York(NY), 10573
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