Is the participant currently receiving services at Indigo? Not currently receiving servicesAlready receiving services
What is the funding source for the participant? NDISPrivateWorkcoverPrivate Health insuranceOther/unsure
Details of person receiving Indigo Therapy services First Name* Last Name*
Date of Birth* Email*
Gender MaleFemaleOther
Address* Suburb*
State*
Postcode*
Who manages the participant's NDIS plan? NDIA ManagedPlan ManagedSelf ManagedMixed
NDIS Plan Start Date
NDIS Plan End Date
Primary Contact for appointment bookings Support CoordinatorFamily MemberCase ManagerLocal Area CoordinatorParticipant / ClientOther
Contact Details: Name* Contact Number * Email Address*
Secondary Contact for appointment bookings Support CoordinatorFamily MemberCase ManagerLocal Area CoordinatorParticipant / ClientOtherN/A
Service(s) Required (You may select multiple) Art TherapyMusic therapyMovement TherapyAnimal TherapyArt Classes
Purpose of Referral*
What is the participant's primary diagnosis/presentation?*
What are the ideal days, times and frequency for the appointments?*
Any other information you would like to tell us?
Please upload any relevant supporting documents ie. NDIS plan, previous assessments, medical history
How did you hear about Indigo? GoogleLOCSupport WorkerPlan ManagerSchoolDoctorFamily / FriendSocial Media Please prove you are human by selecting the key.
