About this template
This National Disability Insurance Scheme (NDIS) Referral Form template is designed for hospitals, general practitioners, and allied health professionals to streamline patient referrals and support requests. It collects comprehensive personal details, disability information, existing care plans, and emergency or guardian contacts in a secure, structured format.
Built to simplify the administrative burden on clinical staff, this form ensures all necessary evaluation data is gathered right from the start. Whether you are coordinating allied health services or submitting documents for eligibility assessment, this template eliminates paperwork chaos and helps get patients the support they need faster.
With Doc2Form, you can easily customize the questions, add your practice logo, and share the form directly with referring physicians or family members. All responses are neatly organized in Google Sheets, making it simple to track referrals and integrate with your existing patient management workflows.
Key features
- Capture patient demographics and NDIS numbers accurately.
- Collect guardian and alternative contact details securely.
- Streamline allied health and support coordination requests.
- Organize all referral data automatically in Google Sheets.
Use cases
- Hospital discharge planners referring patients for community support.
- General practices submitting disability assessment requests.
- Allied health clinics coordinating multidisciplinary care plans.
What this form collects
- Date of Referral (Date)Select the date you are submitting this referral.
- Patient Full Name (Short answer)Enter the first and last name of the referred individual.
- Date of Birth (Date)Enter the patient's date of birth.
- Gender (Multiple choice)Select the patient's gender identity.
- Email Address (Short answer)Provide the primary email address for communication.
- Phone Number (Short answer)Enter the best contact phone number for the patient.
- Residential Address (Paragraph)Provide the patient's current street address, city, and postal code.
- NDIS Number (Short answer)Enter the patient's existing NDIS participant number, if known.
- Primary Disability / Condition (Paragraph)Describe the primary disability, diagnosis, or known support needs.
- Support Requirements (Checkboxes)Select the types of support or coordination needed.
- Copy of Existing NDIS Plan Provided? (Multiple choice)Indicate whether a current NDIS plan document has been attached or provided.
- Additional Supporting Information (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe any other relevant clinical notes.
- Guardian / Next of Kin Full Name (Short answer)Enter the name of the legal guardian or primary next of kin.
- Guardian / Next of Kin Phone Number (Short answer)Provide a direct phone number for the guardian or next of kin.
- Referring Practice / Organisation Name (Short answer)Enter the name of the hospital, clinic, or organization making the referral.
- Referring Professional Name (Short answer)Enter the name of the doctor, nurse, or allied health professional submitting the referral.
- Referring Professional Contact Email (Short answer)Provide your professional email address for follow-up correspondence.
FAQ
Who can use this NDIS referral form?
This form is intended for hospitals, doctors, allied health professionals, and social workers who need to refer individuals for NDIS assessments and support services.
What information does the form collect?
It collects patient personal details, NDIS numbers, disability information, current support coordination, medical practice details, and emergency or guardian contacts.
Can I customize the questions on this template?
Yes! Once you convert or open this template in Google Forms, you can add, remove, or modify any questions to fit your specific clinic or organization's requirements.
How do I share this form with referring doctors?
You can easily share the form via a direct link, embed it on your website, or email it out to partner healthcare providers.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.