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Empowered Therapy and Training Nationwide Referrals ABN: 55 637 079 620

This referral must be actioned: *

Urgently

Within the next 2 weeks

Client Details

Are you a: *

NDIS Participant

Private Referral

If you were referred privately, you are encouraged to complete 10 sessions at a time. Do you agree?

Yes

No

Client/Participant Name

Prefix *

First Name *

Middle Name

Last Name *

Date of birth *

Home Address

Street Address *

Address Line 2

City *

State *

Postal code *

Phone Number & Email

Area Code

Phone Number *

Email *

Current Client Diagnosis ( ASD, OCD etc) *

Next of Kin - Contact #1

Name *

Phone Number *

Email Address *

Home Address *

Relationship to Client/Participant *

Next of Kin - Contact #2

Name *

Phone Number *

Email Address *

Home Address *

Relationship to Client/Participant *

Invoice to

First Name *

Last Name *

Invoicee's Organisation Name *

Invoicee's Phone Number *

Invoicee's Email *

NDIS Participants

Participant Number *

Plan Type *

NDIS-Managed

Plan-managed (organization-managed)

Self-managed

Plan Start Date *

Plan End Date *

Client Budget (specifically allocated for Empowered Therapy and Training services). Please specify whether this is for Capacity Building, Core Supports or Daily Activities/ Other.

*

Therapy
Plan Management
Support Coordination
Support work
Transport
Equipment
Camp
Programs (see below)
Group-base acitivities
Other

Support Coordinator

*

Name
Phone Number
Address
Organisation
Request

Describe Your Goals

Short-term Goals *

Long-term Goals *

Supports Required

Therapeutic Supports

Art Therapy

Counseling

Psychotherapy

Music/Movement Therapy

Dietitian

Sandplay Therapy

Drumming Therapy

Laughter Therapy

Hypno-therapy

Timeline Therapy

Drama Therapy

Neurolinguistic Programming (NLP)

Other

Community/In-home Support Work (for all ages)

Assistance with Daily Personal Activities

Development of Daily Living and Life Skills

Assistance with Daily Life Task in a Group or Shared Living Arrangement including Supported Independent Living (SIL) and/or RESPITE

Participation in Community, Social and Civic Activities (see activities below)

Other

Accommodation

Assistance with Accommodation and Tenancy Obligations

assistance with Coordinating or Managing Life Stages, Transitions and Supports

Assistance with Daily Life Tasks in a Group or Shared Living Arrangement including Supported Independent Living (SIL) and/or RESPITE

Participation in Community, Social and Civic Activities (see activities below)

Group and Centre Based Activities (see activities below)

Other

Employment/Higher Education

Access and Maintain Employment or Higher Education

Specialized Support Employment

Other

Administration

Support Coordination

Plan Management

Other

Education

Life-skills literacy and numeracy program (audits and children)

Adult learning programs

School-aged learning programs

Other

Assessments

Behaviour Support (Includes Positive Behaviour Support Plans)

Mental, Social, Emotional, Behavioural, Cognitive Assessment

Other

Other

Early Childhood Supports

Other

Events (Face to Face or Online)

Half-day Events

Understanding the Children of Today

Parent-Child Connection

Managing Stress and Emotions for Teenagers

Domestic Violence Awareness

Understanding and Living with Autism

Becoming a Life-skills Teacher

Who am I? A journey to Reconnect with One's Self

Mind-setting- if you change your thoughts, you change our life

Full-day Events/ Retreats

Understanding the Children of Today and Parent-Child Connection Bootcamp (3 days)

Understanding and Living with Autism

How NOT to Mess Your Child's Life-Parents/Carers/Teachers Life

MInd-setting-If you change your thoughts, you change your life (advanced level, 3 day retreat)

Who am I? (advanced level, 3 day retreat)

Workshops (for individuals, corporate and private organizations)

Girl's Pamper - self care, self worth day program

From Boys to Men - self care, self worth day program

Laughter Workshop

Drumming Workshop

Laughter and Drumming Workshop

Domestic Violence Workshop

Other

Train the Trainers (opportunity to become qualified facilitators and to gain potential employment)

Authentic Professional Speaker's Course (online and FTF) - learn to become a professional facilitator (2.5 day training)

Laughter Facilitator (2 days)

Drumming Facilitator (2 days)

Camps

Self-esteem school-aged camps

Resilience school-aged camps

Parent and child connection camps

I want to know more about your events *

Yes

No

Any further information you would like us to know:

Files attached (see previous question and tick all that apply)

Past assessment(s)

Past Report(s)

NDIS Plan

Other

Upload past assessments, reports and/or your NDIS plan here.

What Specific Line Item Supports Your Budget *

Read our:

NdIS Support Categories and Support Item Number