STA/RESPITE REFERRAL

Act Believe Achieve Disability Services Respite Referral

This form is designed to be completed by anyone who would like to refer a participant to our Short Term Respite

Participant Details

First Name *

Last Name *

Date of Birth *

Contact Number *

Email Address *

Cultural Background

Does the participant identify as an Aboriginal Torres Strait Islander *

AboriginalTorres Strait IslanderNoPrefer not to say

Living Situation - Other

Participants Address *

Street address *

City *

State *

Postcode *

Carer / Guardian Details

Carer / Guardian Full Name *

Carer / Guardian Contact Number *

Carer / Guardian Email Address *

Carer / Guardian *

Street address *

City *

State *

Postcode *

Accommodation Needs

Level of Support *

Low Support (Supervision Only) Moderate Support (Some Assistance Required)High Support (Full Assistance Required) Complex or Intensive Support

Independent with most daily tasks
May need reminders for meals, hygiene, or medication
Can move around safely on their own

Needs help with some personal care (showering, dressing, toileting)
May need support with meals, mobility, or emotional regulation
Supervision for safety or community access

Needs full personal care and/or mobility support
May require 1:1 support for all activities
Assistance with transfers, continence, medication, or behavioural support

Requires 2:1 support or constant supervision
Complex medical, behavioural, or mental health needs
May have a behaviour support plan, seizure management plan, or communication device

Preferred Date to commence Respite *

How many nights Respite is preferred *

Accommodation History

Has the person accessed Respite before? *

YesNo

Details

Has the person ever been excluded from Respite? *

YesNo

Details

Has there been confirmation of Core Funding to cover the period? *

YesNo

Details

Participant's NDIS Plan Details

How is the Participant's Core Funding NDIS managed? *

Plan ManagedSelf ManagedNDIA Managed

Participants NDIS Number *

Plan Start Date *

Plan End Date *

Approved Short Term Respite Funding *

1:11:21:31:4

What level of Respite funding is included in your plan?

NDIS Plan Attached *

Browse

Please attach a copy of your current NDIS Plan.

Plan Manager Details

Plan Manager Provider *

Plan Manager Contact Name

Plan Manager Contact Number *

Plan Manager Email Address *

Email Address to send Invoices *

Does the Participants have a Support Coordinator *

YesNo

Support Coordinator

Support Coordinator Provider *

Support Coordinator Contact Name *

Support Coordinator Contact Number *

Support Coordinator Email Address *

Participant Representative

Participant Representative Contact Details *

Consent

Do you consent to Act Believe Achieve contacting your Support Coordinator/Plan Manager and/or NDIS regarding this STA Referral *

YesNo

Signature

Signature of person completing Referral *

Draw signature|Type signatureClear

Name of person Signing the Referral *

Relationship to Participant *

Important Notice – Booking Request Only

Please note that submitting this form is a request for Short Term Respite only and does not confirm a booking.
Our team will review your request and contact you shortly to discuss availability, support needs, and final confirmation details.
If your preferred dates are unavailable, we’ll do our best to offer suitable alternatives.

Thank you for your interest in staying with Act Believe Achieve Disability Services — we look forward to supporting you soon!

Save and Complete Later

You have the right not to answer any questions you would prefer not to, however this could impact the quality of supports you receive.

If you have any concerns about completing this form please call

Administration Team on (08) 9594 0010 or email info@abawa.com.au