THE GRAY AREAREFFERAL FORMIf you have any questions, please feel free to contact us. Referrer Information Name First Name Last Name Email Phone (###) ### #### Brief overview of relationship to client * Client Type * Medicare NDIS Participant OOHC Other Services Required Psychology Occupational Therapy Positive Behaviour Support Individual Safety Plan Post Crisis Response Client Information Client Full Name * First Name Last Name Preferred Name D.O.B Age Preferred Pronoun Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Email Guardian 1 Information Guardian 1 Full Name First Name Last Name Guardian 1 Phone Guardian 1 Email Guardian 1 D.O.B Nature of Parent's Relationship *Required for children under 18 Together Separated Divorced Defacto Other Relationship to Client Preferred Contact for Client * Client Guardian Referrer Other Prefered Contact Method * Text Email Call If you selected 'Other', please provide details of contact Name, relationship to client, email, phone and other information you think we would find useful. Medicare Information Please fill this section in if you are referring someone to The Gray Area who has a Medicare Mental Health Care Plan. Referring Clinician's Name Referring Clinician's Practice Medicare Number Expiry Client IRN NDIS Information Please fill this section in if you are referring someone to The Gray Area who has an NDIS Plan. NDIS Fund *The Gray Area is working towards becoming a registered NDIS service provider in order to assist NDIS/ Agency managed participants. Please feel free to contact us regarding ways we can assist with your current funding application. Self Managed Plan Managed NDIA / Agency Managed NDIS Number NDIS Plan Dates Fund Manager Name (if applicable) Fund Manager Email (if applicable) Further Information Additional Information Please provide any additional information to ensure a smooth onboarding process. Thank you!
