SPARROW COLLECTIVE
Level 1, 208 Whitehorse Rd
Balwyn VIC, 3103
sparrowcollective.com.au
ABN 19 640 884 028

Referral Form

Thanks for choosing Sparrow Collective. We have all our services detailed on our website. We accept referrals for people with NDIS plans that are over 16 years of age who are living with intellectual and/or psychosocial disabilities. Our community hub is in Balwyn, Melbourne, and we can travel to you. Please contact us if you are unsure of our availability to travel to a particular location.

SECURE DATA

Australian based servers and SSL encryption is used to securely transport and serve data collected from this form.

Participant Consent

By ticking this box, the participant gives their consent for their information to collected by Sparrow Collective for the purposes of administration and supporting them with our services. The information is stored in accordance with our Privacy and Confidentiality Policy. *

Participant Details

First Name *

Last Name *

Preferred Name (if different)

Date of birth *

Gender *

Address *

Phone *

Email *

NDIS number *

NDIS plan end date *

Please select one of the following *

Plan ManagedSelf Managed

Email address for invoices *

Emergency Contact

Full Name *

Relationship *

Phone *

Support Coordinator / Advocate Details

Full Name *

Role *

Support CoordinatorFamilyAdvocateOther

Email Address *

Phone *

Setting up the First Meeting

I would like this to be organised via my Support Coordinator / Advocate

I would like to be contacted directly to arrange

Preferred contact method

What services you are interested in?

What days are you available?

How can we best support you?

Please confirm the following

Psychosocial Intellectual disabilityOther

Diagnosis (if consent to share)

What goals do you want to achieve with these services? *

What are your passions or interests? *

Worker Preferences (please detail if needed)

Is there anything we should be aware of to best support you or do we need to provide a specifically experienced worker?

Please upload any relevant documentation such as NDIS Plans, reports or risk assessment (if you have consent to share)

Browse

.

Browse

Funding Details

Our services are offered under various line items, which enables budget flexibility. The service price will reflect the line item price in the NDIS Price Guide. Please select which line item you would like the service under:

Support Work

Core: Access community, social and Recreational Activities 04_104_0125_6_1

Support Work- Personal Training focus

Core: Access community, Social and Recreational Activities 04_104_0125_6_1Capacity: Personal Training 12_029_0126_3_3Capacity: Improved Daily Living 15_037_0117_1_3

Support Work- Song Writing & Recording focus

Core: Access community, social and Recreational Activities 04_104_0125_6_1Capacity: Life transition planning including mentoring, peer support and individual skill development 09_006_0106_6_3

Therapy (Art & Dance Movement)

Core: Assessment Recommendation Therapy or Training Supports - Other professional 01_741_0128_1_3 Capacity: Assessment Recommendation Therapy or Training- Art Therapy 15_610_0128_1_3 (Art Therapy only)Capacity: Assessment Recommendation Therapy or Training- Other professional 15_056_0128_1_3 (Dance Therapy only)

Programs

Core: Access community, social and Recreational Activities 04_104_0125_6_1Capacity: Skills Development and Training 09_009_0117_6_3Capacity: Life transition planning including mentoring, peer-support and individual skill development 09_006_0106_6_3Capacity: Improved Daily Living 15_037_0117_1_3

How did you hear about us?

Newsletter

If you'd like to stay up to date with our Programs and Services, feel free to join our newsletter by clicking the button below.

Join Our Newsletter

Anything Else?

This is a space to write anything else you wish to :)

HAVE A GREAT DAY AND THANKS FOR THE REFERRAL

Save and Complete Later