Empoweredtherapyandtraining.com



Empowered Therapy and Training NDIS ReferralsClient DetailsReferred ByClient/ Participant Name ? OrganisationDOB? Child Safety Services Participant no. #? SchoolPlan Start Date? Medical Clinic Plan End Date? HospitalClient Address? NDIA/NDIS Phone Number? Private Client Budget? Other Therapies$Support CoordinatorEquipment$NameTechnology supplies $Phone Number? Parent ? Guardian/ Carer ? Other AddressNameOrganisationPhone Number Request Email AddressPlan: ?NDIS-managed ? Organisation-Managed ? Self-ManagedFiles Attached (please tick all that apply)Invoice to: [Email Here]? Past Assessment ? Past Reports ? NDIS Plan ? Other: Attention to:(name)Current Client Diagnoses:(ASD, Autism, OCD etc)Short Term GoalsLong Term Goals 1. 2. 3. 4. 1. 2. 3. 4. Therapies/ Support Required – (please tick all that apply)Programs 6661151333500? Life-skills education ? Life-skills workshops ? Daily-living programs (youth & adult)? Job seeking workshops ? Youth self-esteem and resilient camps ? Girls’ pamper workshop (self-care) ?From boys to men workshop ? Parent-child connection workshops ? Managing emotions and stress in teenagers workshop? Understanding children of today workshop? Understanding children in care workshop? Wellness Workshop? Mind-setting Workshop?Domestic Violence Awareness Workshop?Laughter and Drumming Workshop ? Kool Kids Tutoring Literacy/Numeracy –Youth & Adult programs)I want to know about more programs and workshop?? Art Therapy? Drumming Therapy? Counselling ? Laughter Therapy ? Psychotherapy ? Hypno-therapy ? Music/Movement Therapy ? Timeline Therapy ? Dietitian ? Drama Therapy ? Teacher/Trainer ? Neurolinguistic Programming (NLP)? Support Workers (in- conjunction with other organisations) Must be actioned by? Urgent ? Within the next 2 weeks ? Other:________________________(please provide time frame)Reports Required (please tick all that apply)? Therapies Report ? Dietitian Report ? Teacher Report ? Other: _____________________________Date required by:-101601841500Therapeutic Support (0128)Finding and keeping a job/ improved health and well-being/ improved daily livingNDIS Support Item NumberPrice-184153048000Play-based therapiesArt therapy, music/dance therapy etc01_741_0128_1_3$193.99/hr-184151968500Psychotherapy 01_741_0128_1_3 $193.00/hr-184154127500Teacher/Trainer 01_741_0128_1_3$193.99/hr-1333519748500Dietitian Consultation and Diet Plan Development(individual dietary advice)12_025_0128_3_3$193.99/hrDietitian Consultation and Diet Plan Development-184152667000Group based dietary advice (group of 3)12_026_0128_3_3$64.66/hrEarly Intervention Supports for Early Childhood (0118)-139704826000Between 0 to 6 years of ageImproved daily livingNDIS Support Item NumberPrice-635022923500Capacity Building Supports For Early Childhood Interventions - Other Therapy01_740_0118_1_3$193.99/hrLiteracy/numeracy early childhood programs, play-based community activities, social, emotional, mental behavioural, physical and mind setting understanding. Connecting families together for knowledge and understanding.-808074190943Preferred Starting Date:Preferred dates/times that the participant is available:00Preferred Starting Date:Preferred dates/times that the participant is available:-6804841756140Any further information: ................
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