Online Referral

Make a
Referral.

Complete this form to refer a participant to The Empowerment Project. We respond within 24 hours of receiving your referral.

24 hrs

Response

NDIS

Registered

All

Plan types

Step 1 of 5

Participant details

Tell us about the person being referred. All fields marked * are required.

Personal information

First name *

Last name *

Date of birth *

Gender

Preferred language

Contact details

Phone *

Home address *

Living situation

Current living situation

Lives alone

With family

With carer

Supported accommodation

Other

Step 1 of 5

Step 2 of 5

NDIS Plan details

We need this to confirm funding before booking your first appointment.

Plan information

NDIS number *

Plan end date *

Plan management type *

Primary disability / diagnosis

Diagnosis or condition *

Brief background (optional)

Step 3 of 5

Services requested

Select all that apply. You can request multiple disciplines — our team coordinates directly.

Which services are you requesting? *

Occupational Therapy

Physiotherapy

Podiatry

Dietetics

NDIS Reporting

Appointment preference

Preferred location

Home visit

Community

School / workplace

No preference

Goals or priorities for support

Step 4 of 5

Contacts & safety

This helps us reach the right people and ensures the safety of our clinicians before visiting.

Referring person

Your name *

Relationship to participant *

Your phone *

Your email

Safety & access information

Any safety considerations for home/community visits?

Step 5 of 5

Review & submit

Please confirm the details below before submitting. We will contact you within 24 hours.

Consent & declaration *

I confirm that the participant (or their authorised representative) has consented to this referral and the sharing of their information with The Empowerment Project.

I understand that The Empowerment Project will contact me to confirm funding and appointment details before any services commence.

Referral received.

Thank you — we have received your referral and will be in touch within 24 hours to confirm funding and book your first appointment.

Back to Home

Prefer to call?

We are happy
to help.

Call us and we will complete the referral with you over the phone.

(02) 9052 0841

Make aReferral.