LifeAccess Referral Form

Please choose one of the following options: *

I am referring myself

I am referring another person

Name and contact details of person completing this form (if referring another person)

Full Name of person being referred *

Date of Birth of person being referred *

Address of person being referred *

Email Address of person being referred *

Phone Number of person being referred *

What is the funding source? *

NDIS

iCare

Other insurance scheme/company

Self-funded

Other

Funding ID Number: *

Details regarding funding (contacts, company, funds management method, etc): *

Diagnosis *

Approx date of onset

Are there any other relevant medical conditions in addition to the primary diagnosis?

Other relevant information that may impact our intervention (e.g. upper limb function, mobility, cognition, communication, availability, etc.)

Services Requested

Computer Access:

Desktop/laptop

Tablet

Please provide details regarding computer access:

Phone Access:

Landline

Mobile

Office

Please provide details regarding phone access:

Environmental Control:

Doors

Lights

Blinds

Intercom

Air conditioning

Fan and heater

Alert system

TV and movies

Music

Who owns the home?

Owner occupied

Rental

Housing NSW

Other (please provide details)

Please provide details regarding environmental control:

Recreation:

Video gaming

Remote control cars and other RC vehicles

Drone flying

Please provide details regarding recreation:

Communication:

Augmentative and Alternative Communication (AAC)

Alert and emergency call systems

Video calling

Assistive listening AT for deaf/hearing impaired

Please provide details regarding communication:

Other Electronic Assistive Technology:

Reading and writing supports

Low vision and blindness supports

Cognitive supports

Other (please provide details)

Please provide details regarding other electronic assistive technology:

LifeAccess Referral Form

Services Requested

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