Referral Form

Thank you for considering Emerald Kintsugi’s specialised support services for your NDIS participant. This form is designed to help us gain insight into the participants’ needs and goals, ensuring that our services effectively align with their NDIS plan outcomes. Our services focus on building capacity through a neuroaffirming approach that celebrates diverse minds.

    I am a*
    Support CoordinatorPlan ManagerSelf-Managed ParticipantParent/Guardian

    Your Name*

    Organisation (if applicable)

    Email*

    Phone*

    Participant Details (if different from above)

    Participant Name

    Participant Age

    NDIS Number

    Plan Start Date

    Plan End Date

    Services Required
    Please select all that apply:

    If Other, please specify:

    Relevant NDIS Goals
    Please select all that apply:

    If Other, please specify:

    Additional Information

    What would you like us to know before we meet?

    Preferred contact method*
    EmailPhone

    Preferred time for contact

    How did you hear about us?

    Emerald Kintsugi adheres to the Privacy Act 1988 (Cth), NDIS Quality and Safeguards Commission requirements, and the Australian Privacy Principles. Information collected will only be used for providing appropriate support services.

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    Next Steps:

    1. Please email the completed form to emeraldkintsugi@gmail.com
    2. Our team will contact you within 3 business days to discuss the referral
    3. A service agreement will be provided before commencing services

    Thank you for your referral. We look forward to supporting your participant’s journey with Emerald Kintsugi.

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