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Referral & Request for Service Form

Refer to us: If you are a Planner, Local Area Coordinator, Support Coordinator, Plan Manager, GP, Caregiver or other service provider interested in accessing Wild child & CO services for your patient or client, we’d love to connect. 

Request Service: If you are looking to engage with our services direct as a Private client please use this form as well to start your journey with us.

Click the button below to start.

Start

Question 1 of 21

Referrer Details - Include Full Name, Organisation, Phone Number & Email Address 

Question 2 of 21

Who should we contact & how?

Question 3 of 21

Our Office Hours are: 

When is the best time to make contact?

(Select all that apply)
A

Monday 8 - 11 am

B

Tuesday 11 - 1

C

Wednesday 11 - 1

D

Thursday 8 - 11am

E

Friday 8 - 10 am

Question 4 of 21

Who is the client? Include full name, age, phone number, home address & email address

Question 5 of 21

Are we able to contact the client direct?

A

Yes

B

No

C

No client is a Child

Question 6 of 21

How will the client be paying for your service?

A

Private

B

NDIS Self & Plan Managed

C

Other (workplace, agency)

Question 7 of 21

Services required 

(Select all that apply)
A

Trauma Sensitive Yoga Group Program

B

New Choice

C

New Choice

D

New Choice

E

New Choice

Question 8 of 21

Days Client is Available/Looking for Services 

(Select all that apply)
A

Monday

B

Tuesday

C

Wednesday

D

Thursday

E

Friday

F

Saturday

G

Sunday

Question 9 of 21

Additional information around available time including time of day and frequency of service required 

Question 10 of 21

Are there any Conditions/Diagnosis we should be aware of?

Question 11 of 21

Please outline any challenging behaviours including allergies, triggers, sensitivities 

NDIS Participants

If you are currently a NDIS participant please complete the following information.

Question 13 of 21

Participants Full Name, Date Of Birth & NDIS Number

Question 14 of 21

If you are plan managed who is the plan manager? Who should invoices be directed to? If no plan managed leave blank or type self managed.

Question 15 of 21

Who is your coordinator of Supports include name, organisation name, phone number & email address (leave blank or type N/A if you currently do not have a COS)

Question 16 of 21

Current NDIS plan start & end date

Question 17 of 21

What budgets would you like to use? this helps us tailor make your program for you. ( you can choose one or both)

(Select all that apply)
A

Core

B

Capacity

Question 18 of 21

NDIS Goal 1: 

Question 19 of 21

NDIS Goal 2: 

Question 20 of 21

NDIS Goal 3:

Question 21 of 21

NDIS Goal 4: 

Confirm and Submit