ssrc referralFIll out the form below to make a referralPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Young Person’s DetailsFull Name *Date Of Birth *Does this client identify as either:Aboriginal and/or Torres Strait IslanderCALDPR StatusInterim OrdersPermanent OrdersPR to parentsCaseworker/Referrer DetailsFull Name *PositionAgency & ProgramPhone *Email AddressDoes this young person identify as having a disability? *YesNoDiagnosis: *Is this young person currently accessing the National Disability Insurance Scheme (NDIS)? *YesNoNDIS Number * disability? person Birth Plan Start Date *Plan End Date *Does this young person have a Support Coordinator (COS)? *YesNoCOS Email *COS Contact NumberPlease advise if any of the below is applicable, please also upload relevant documentation below:Section 14 OrderCustody / Legal Orders (Domestic & Family Orders/Arrangements)Youth Justice InvolvementAOD Substance AbuseRisk or history of self-harm or suicidal ideationDoes this young person currently have any of the following supports in place:Occupational TherapySpeech TherapyBehavioural SupportPsychologyPsychiatryIn Home/Community SupportsReason for referralRelevant historyUpload any relevant documentation here Click or drag files to this area to upload.You can upload up to 5 files. Submit call us 02 7233 4745 Email Us admin@empowermentcs.com.au Opening Hours Mon-Fri 9AM to 5PM Sat-Sun: Closed Visit Us 30 Foundry Road Seven Hills, 2147 NSW Looking for something else? ndis services careers
