Client Details

Referral Date *

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address *

City *

State *

Postcode *

Gender

FemaleMaleOther

Preferred Way of Being Contacted *

Phone callSMSEmail

Best time to contact you (optional):

Morning (8am-12pm)Afternoon (12pm - 4pm)Evening (4pm - 6pm)

Consent to contact *

I consent to Northern Star Support contacting me using my selected method above for service-related communication.I DO NOT consent to Northern Star Support contacting me using my selected method above for service-related communication.

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Email Address

Street Address

City

State

Postcode

Education Setting *

No Educational SettingDaycarePre-SchoolSchool

Name and Location of Educational Setting

NDIS Details

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

NDIS Number (If you do not have an NDIS plan type 1234) *

Plan Start Date *

Plan End Date *

Referrer Details (Person Making the Referral)

First Name *

Last Name *

Relationship to Client *

Agency

Role

Email Address *

Phone Number *

I have obtained consent from the participant to make this referral and provide Northern Star Support with the participant's personal and medical details. *

Reason For Referral

Reason For Referral/Relevant Medical Information *

File Upload (Please attach a copy of the current NDIS plan if possible and any other reports you may have)

Browse

If you require assistance in unloading your plan - Please give Admin a call on 0411 304 085 and they can guide you through this process.

What Happens Next

Once this form has been submitted, Northern Star Support will review the information provided and contact you to arrange a Therapy Planning appointment.

The Therapy Planning appointment involves collecting information about the participant’s development, strengths, and areas of need. This may include discussion with the participant’s parent/carer, review of relevant reports, and informal assessment activities where appropriate.

Prior to the Therapy Planning appointment, a Service Agreement (SA) and Schedule of Supports (SOS) will be issued for your review and signing. These documents will be set up for up to 3 hours. This time may include both the face-to-face Therapy Planning session and related professional activities, such as preparation, review of reports, and documentation. Only the actual time used will be billed, with any unused time nilled.

The face-to-face Therapy Planning appointment will run for approximately 1.5–2 hours, depending on the complexity of needs and information required. The appointment is typically conducted with the participant’s primary carer, with participant attendance where appropriate. A service report summarising what was discussed will be provided to the family following the session.

This service is charged in line with the NDIS Pricing Arrangements and Price Limits (PAPL).

If you have any questions at any stage, our team will be happy to discuss the process with you prior to services commencing.

Confirmation *

I understand the Initial Consultation process, the next steps, and that services will not commence until the Service Agreement and Schedule of Supports have been signed.