Assessement Referral I am a participantI am a Referrer or Nominated Representative If you need any help while completing this form, please contact our friendly team on 1300 451 494 or by email at info@bewellco.com.au Your Details Referrer/Plan Manager Email* Your role ParentSupport PersonLAC/Support CoordinatorTeacherDoctor/SpecialistInsurerSolicitorAllied Health ProfessionalPlan ManagerOther (please specify) Participant / Client Details First name Last name Preferred name Preferred pronoun Email address Date of birth Suburb State Post code Reason for referral Services required How would you/participant prefer to receive our services? TelehealthFace-to-faceEither Which services are you/participant interested in? Psychological AssessmentNeurodevelopmental DisordersSpecific Learning DisordersIntellectual Ability (learning difficulties and giftedness)NeurocognitiveMedico-legal AssessmentsMental Health DiagnosisFunctional Capacity AssessmentsEmployment-related Assessment and counsellingI am unsureother (please specify) Do you have an approved NDIS plan or are you awaiting approval? NoI have an approved planI am awaiting approval Plan Details NDIS participant number (if available) Plan Start Date Plan End Date How will funds be claimed? Insurance managed claimWorkers Compensation claimOther (please specify) Plan Manager/Referrer Name Plan Manager/Referrer Company Plan Manager/Referrer Phone Attach documents For multiple documents, compress them into a ZIP folder and upload. Ensure the total size is under 5MB. Tell us more about the Participant / Client Reason for referral Primary disability, injury or illness Other relevant health information Is there a Guardian involved? YesNo Is there a Support Coordinator involved? YesNo Who is the Plan Nominee or Child Representative? YesNo Will an interpreter be needed? YesNo