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Client details and Relevant NDIS Plan Details
(N/A if this is a request for service for staff learning & development, service reviews etc.)
Client Name
*
Address
*
Current NDIS Plandates
*
Specialist BehaviourSupport funding is
*
Phone Number
Age and DoB
*
NDIS No
*
NDIS Plan NomineeDetails
*
Details of Person making Referral/ Requesting Service
(Person nominated below will be invoiced, except for ‘agency managed’ or ‘plan managed’NDIS participants)
Name
*
Organisation
*
Email
*
Position
*
Telephone/Mobile
*
Postal Address
*
Additional Contact Person 1 Details
(for e.g.: for information, invoicing/plan manager details, service site contact etc.)
Name of person
*
Telephone/mobile
*
Email
*
Specify Role(in relation to thisreferral)
*
Postal/Address
*
Additional Contact Person 2 Details
(for e.g.: for information, invoicing, service site contact etc.)
Name of person
*
Email
*
Postal/Address
*
Specify Role(in relation to thisreferral)
*
Telephone/mobile
*
Custody/Court Orders
The Early Childhood Partner needs to understand the environment that the child lives in andwho best to contact about your child. This includes knowing about existing parenting,custody or guardianship arrangements
Are there any existingparenting, custody orguardianshiparrangements for thechild?
*
Yes
No
If Yes, please specifyand provide copies withthis application
*
Language/Interpreter
The main language isspoken at home:
*
Is an interpreterrequired for a phoneconversation?
*
Yes
No
Service Required
List the services the Participant requires and any referral dates etc.
Service
Referral Date
Other Notes
Reason for referral
Accessing your personal and health information
The authorized representative of your child (e.g. parent, guardian or carer) can seek to access the personal and health information about the child that is held by MelbourneGenuine Care Pty Ltd.
You can contact the Managing Director on mandgcare@gmail.com. They can help answerquestions you may have and will assess your application by using the criteria in MelbourneGenuine Care’s Privacy and Confidentiality Policy. They will consult with you to clarifyyour request and decide whether documents can be released in full or are exempt orpartially exempt.
Storage of personal and health information
Information collected about your/your child will be stored securely on databases administered by Melbourne Genuine Care Pty Ltd/NDIS. Only authorized personnel will have access to the information stored on the database.
More information about the NDIA’s collection, use, disclosure and storage of your/your child’s personal information can be accessed at the NDIA’s website which includes theNDIA’s Privacy Policy at www.ndis.gov.au/privacy.
Parent/Carer Consent
I have read and understood the General Information and Important PrivacyInformation provided with this information form.
I understand how myself/child’s personal information will be collected, used anddisclosed for the purposes of the NDIS, which is set out in this information form.
I have carefully read all of the information provided in the information form andconfirm that it is accurate, complete and up to date.
I consent to, Melbourne Genuine Care Pty Ltd collecting, using and disclosingpersonal and sensitive information about myself/child in accordance with theGeneral Information and Important Privacy Information sections in this document.
I understand that I may withdraw consent to receive support from, MelbourneGenuine Care Pty Ltd service provider at any time.
I give permission to contact the professional completing/assisting with thisinformation form (if any).
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