07 3106 0301
info@sunrisecare.au
NDISPrivate funding (Self-funded)Other
Participant Reference number*
How is the plan managed financially?* NDIA managedSelf-managedPlan managed
Plan start date
Plan end date
Client reference number:
Programme / Funding details*:
Referrer type* Support CoordinatorCase ManagerSocial WorkerHealth Care ProfessionalOtherNone / Not applicable
Organisation*
Contact*
Referrer email*
Referrer phone*
Salutation* Select optionMrMissMrsMsMxDrProfJudge
First name*
last name*
email*
phone*
Date of birth*
Gender* Select optionMaleFemaleNon-binaryTransgenderOther
Are you of Aboriginal or Torres Strait Islander origin?*: Select OptionYesNo
AboriginalTorres Strait IslanderBoth
Street address line 1*
Street address line 2
Suburb*
State* Queensland – South East Queensland area
Postcode*
Primary contact name
Primary contact relationship
Primary contact email
Primary contact phone
Primary disability* Select optionDementiaAutismPsycho-social / Mental healthSpinal cord injuryAcquired Brain Injury (ABI)StrokeIntellectual DisabilityDevelopmental DelayGlobal Developmental DelayOther neurologicalVisual ImpairmentHearing ImpairmentOther physicalMultiple SclerosisCerebral PalsySpeechOther SensoryOther – please specify
Primary disability other*
Secondary disability Select optionDementiaAutismPsycho-social / Mental healthSpinal cord injuryAcquired Brain Injury (ABI)StrokeIntellectual DisabilityDevelopmental DelayGlobal Developmental DelayOther neurologicalVisual ImpairmentHearing ImpairmentOther physicalMultiple SclerosisCerebral PalsySpeechOther SensoryOther – please specify
Secondary disability other
Does the participant have a Behavioural Support Plan (BSP) or is there funding for Behavioural Supports in their Plan?* Select optionNoYes
For individual supports (disability support worker) we cannot accept participants with a Behavioural Support Plan because we are not set up to meet the additional requirements for providers when a BSP is in place. For nursing services, we can accept participants with a BSP for our partners.
Are there any behaviours of concern or identified risks?* Select optionNoYes
Please Provide Details
Community & Social Participation Describe:
Describe:
Household Tasks Describe:
Innovative Community Participation Describe:
Life Stages & Transitions Support Describe:
Medication Management Describe:
Supported Employment Describe:
Travel/Transport Assistance Describe:
Assistance Animals
Community Nursing Care
Daily Living & Life Skills Development
Daily Personal Activities Assistance
Group & Centre-Based Activities
High Intensity Personal Activities
Shared Living Daily Tasks
Specialised Support Coordination
What is the maximum budget allocated in the plan for the core supports to be provided by us?*
What is the maximum budget allocated in the plan for the capacity supports to be provided by us?
Does the participant have high intensity funding?* Select optionNoYesUnsure
Are there any support worker / carer preferences or specific skills requirements?*:
Please provide a brief overview of goals, care / support requirements and any other relevant information*:
What days and times is support / care required or if unknown approximately how many hours per week?*: Note: Minimum shift lengths may apply
Are there any smokers in the home?* Select optionNoYes, but they only smoke outsideYes, and they smoke insideUnsure
Are there any pets in the home?* Select optionNoYesUnsure
Is there anyone in or around the home who could pose a security risk?* e.g. IV drug use, alcohol abuse, history of violence or abuse. Select optionNoYesUnsure
Are there any weapons or firearms on the premises?* Select optionNoYes, they are locked upYes, they are not locked upUnsure
Is the property a multi-story building?* Select optionNoYes with lift accessYes with access via stairsUnsure
Is street parking available?* Select optionNoYesUnsure
Will an access code be needed to enter the property?* (If yes, please provide it before services commence.) Select optionNoYesUnsure
Is the property located in a known fire danger area?* Select optionNoYesUnsure
Please provide any additional information Rules: 200 words
Are there any allied health, psych assessments, care/support plans or other relevant reports? Please attach here
Drop files here or Select files (Max. File size: 128 MB)
To express your interest in support services, contact our friendly team by phone, email, or website.
We arrange a one-on-one consultation to understand your needs, preferences, and goals.
Together, we create a personalised plan designed to suit your lifestyle and NDIS goals.
Start receiving compassionate, person-centred support tailored just for you.
