Leveled Abilities | Disability Day Program & Support Melbourne

Referral

Participant Details

Title / Pronouns (eg. he/she/they)

First Name *

Last Name *

Date of Birth *

NDIS Number *

Address *

Phone

Type of Living Arrangement *

Parent / Carer / Representative Details

First Name *

Last Name *

Relationship to Participant *

Email *

Mobile Phone Number *

Would you like to be the official next of kin? *

If no, please specify next of kin with contact details

Details of Support Coordinator (if applicable)

Medical History

Please list formal diagnosis/diagnoses of participant below (if applicable, please also include mental illness). Write 'none' if participant has no medical history to report.

1. *

Epilepsy? Please provide further detail if applicable (e.g. triggers, management plan): *

Dietary Requirements? Please provide further detail if applicable (e.g. nut allergy, gluten intolerance): *

Allergies? Please provide further detail if applicable (e.g. triggers, management plan): *

Please specify if staff will need to administer or prompt medication: *

Name three activities the participant would enjoy attending (e.g. beach walk, sport, music, cooking)

Is there any further information regarding the care and safety of the participant? *

Funding

Type of NDIS Plan *

Please send service invoices to *

Enter the plan manager's email address or the parent/guardian's email directly.

Privacy and Consent

At Leveled Abilities Day Program, we are committed to providing high-quality, person-centred support in a safe, respectful, and inclusive environment. To deliver our services effectively, we may collect personal, health, and support-related information from participants and/or their nominated representatives.

This information is used solely to support the participant's wellbeing, ensure the safe delivery of services, and meet our legal and operational obligations. Information may be shared with relevant staff members, support workers, healthcare professionals, or other authorised parties where necessary to provide appropriate care and support, or where required by law.

All personal information is handled in accordance with privacy legislation and strict confidentiality standards. Access to participant information is limited to authorised personnel who require it to perform their role and act in the participant's best interests.

If you have any questions or concerns regarding privacy, confidentiality, or the management of your information, please contact the management team at Leveled Abilities Day Program.

Participant Consent

I acknowledge that Leveled Abilities Day Program may collect, store, and use my personal and health information for the purpose of delivering safe, effective, and individualised support services.

I understand that this information will be managed confidentially and may be shared with authorised personnel or service providers where necessary to support my care, safety, and participation.

By signing below, I provide consent for Leveled Abilities Day Program to collect, store, and manage my information in accordance with its Privacy and Confidentiality Policy.

I agree — Client / participant signature (or parent / guardian signature if acting on behalf of the participant).

Please print name *

Date *