NDIS Psychotherapy Referral Form

    Parent/Carer Details

    Participant Details

    Cultural Identity:

    NDIS Plan Details

    Plan Management Type:

    Reason for Referral

    (Please include relevant background, trauma history if known, current behaviours or symptoms, and
    purpose of therapy)

    Relevant NDIS Goals

    (Can be taken from the NDIS plan)

    Type of Support Requested

    Preferred Delivery

    Attach supporting documentation

    Case plan summary

    Previous assessments/reports



    Additional Notes

    (Include any risk issues, interpreter requirements, history of engagement with therapy, etc.)