NDIS RESIDENTIAL MODIFICATIONS REFERRAL FORM

In confidence, when completed.

1. PARTICIPANT DETAILS:
Surname: Click or tap here to enter text.	Given Name(s): Click or tap here to enter text.
Address: Click or tap here to enter text.	NDIS number: Click or tap here to enter text. NDIS plan dates: Click or tap here to enter text. Is copy of plan attached: Choose an item.
Date of Birth: Click or tap here to enter text.	Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.	Interpreter required: Choose an item. Language: Click or tap here to enter text.
Living arrangements: Click or tap here to enter text.
Contact Person 1 Name: Click or tap here to enter text. Address: Click or tap here to enter text.	Relationship to Participant: Click or tap here to enter text. Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.
Contact Person 2 Name: Click or tap here to enter text. Address: Click or tap here to enter text.	Relationship to Participant: Click or tap here to enter text. Phone: Click or tap here to enter text.
Email: Click or tap here to enter text.

3. REFERRER DETAILS: ☐ Check this box if referring yourself
Name: Click or tap here to enter text. Organisation: Click or tap here to enter text. Phone: Click or tap here to enter text. Email: Click or tap here to enter text. Role: Click or tap here to enter text.

4. HOME MODIFICATION/S REQUIRED: [please attach 4 -6 photos]
Details: Click or tap here to enter text. A Scope of Works may also be attached.

5. QUOTING SERVICES:
Mode Renovations quotes all home modification works individually. A representative will attend the home, with an Occupational Therapist or similar, where recommended. Visual inspection, discussions with stakeholders and check measurements will be compiled and a comprehensive quote provided.

6. SAFETY & WELFARE: Tick if Yes
Is anyone at the Participant’s property known to display any aggressive behaviour?	☐
Is there anything at the property that can pose a risk to our staff [e.g. tripping hazards, hoarding etc…]?	☐
Have any pets at the property ever displayed any aggressive behaviours?	☐
Other Please specify:	☐
7. PAYMENTS
Who is responsible for paying invoices related to this project? (Please select one) ☐ NDIA ☐ Self-Managed ☐ Participant’s Nominee ☐ Registered Plan Management Provider Name of Plan Management Provider (if applicable): Click or tap here to enter text. Participant / Nominee / Providers name for the account: Click or tap here to enter text. Phone: Click or tap here to enter text. Please provide an authorised contact name and email address for Mode Renovations to send a contract and invoices to: Contact name: Click or tap here to enter text. Email address: Click or tap here to enter text.

8. ADDITIONAL INFORMATION if required:
Click or tap here to enter text.

DECLARATION BY PERSON COMPLETING THIS FORM:

I understand that the information provided in this form remains confidential and shall not be used for any purpose other than as required to provide home modifications to the Participant.

☐ I authorise Mode Group t/a Mode Renovations to use the information provided in this form to compile a quote on my/the client’s behalf.

☐ A line item will be created to enable access to funds for payment of the progress stages of works.

Signed (insert name):	Date:

Click or tap here to enter text.	Click or tap to enter a date.

Signature/Digital Signature:

Click or tap here to enter text.

Mode Group, helping to improve access and liveability in the homes of NDIS participants.