Referral Form - NDIS Access Support
First Name
Last Name
Mobile Number
Email Address
Postcode
I am making this referral (select one)
for Myself.
On behalf of someone else.
Referrers Name
Relationship to Applicant
Referrer Contact Number
Referrer Email
Is the applicant their own decision maker?
Yes
No
Unsure
Decision Maker Name
Decision Maker Email
Decision Maker Contact Number:
Primary Diagnosis
Secondary Diagnosis (List)
What diagnosis do you recognise as your primary (most impactful) impairment, and why?
List all medical and specialist contacts currently involved in your care
The applicant holds an Australian Citizen / Permanent VISA Holder / Have a special category VISA
Yes
No
The applicant has completed the NDIS Access request process before
Yes
No
When was the previous application submitted?
What reasons were given for the application being declined?
Please upload a copy of the previous decision letter from the NDIA
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Do you have any recent assessments, letters or documents that may support your application to to the NDIS?
Yes
No
File 1
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File 2
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File 3
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File 4
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File 5
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Questionnaire
Do you have a documented permanent disability or medical condition?
Yes
No
Has your disability or condition significantly affected your ability to carry out everyday activities for at least the past 6 months?
Yes
No
Is your disability likely to be permanent or long-term?
Yes
No
Do you require support to participate in everyday activities (e.g., self-care, mobility, communication)?
Yes
No
Does your condition affect your ability to work, study, or participate in community activities?
Yes
No
Unsure
Do you require assistance with daily tasks or equipment to support your independence?
Yes
No
Are you under 7 years old and experiencing developmental delays?
Yes
No
Has a medical professional (GP, specialist, therapist) confirmed your disability or condition?
Yes
No
Do you require ongoing therapy (physiotherapy, occupational therapy, speech therapy) to manage your condition?
Yes
No
Are you already receiving support from another government program (e.g., My Aged Care, SASH, Commonwealth Funded Program)?
Yes
No
Unsure
Is there any further information you'd like to provide regarding your enquiry to access the NDIS?
Please wait, files are uploading..
Submit
