REFERRAL FORM

Experience the Butter
Fish difference

For all general enquiries, please contact us on 1300 020 271 or send information to
admin@butterfish.com.au. A member from our team will call you to arrange a consultation.

In the meantime, send us some information about the type of service/s required so we can get
a better idea of what you need as well as provide you with a more accurate quote.

Make A Referral

Where did you hear about Butter Fish Services?

Referrer Details

Date of Referral

Organisation

Phone Number

Email

Relationship

Address

Who is to be contacted for scheduling of appointments?

Relationship

Organisation

Phone Number

Email

Do you consent for Butter Fish Services to initiate services in line with the Service Agreement?

Yes No

Participants details

Date of Birth

Gender

Phone Number

Email

Residential Address

Suburb

State

Postcode

Plan Nominee/ Person responsible (Authorised to sign service agreements)

Signatory for Service Agreement?

Yes No

Relationship

Guardian?

Yes No

Phone number

Email

Address

Preferred way to be contacted

Best time to contact

Country of Birth

Cultural Background

Primary Communication

Interpreter required?

Yes No

If Yes, what language?

Hearing

Vision

Mobility

Living arrangements

Assessments

Yes No

Assessment Type

Support Coordination

Yes No

Support Coordination Type

Psychology

Yes No

Frequency of Psychology Service

Counselling

Yes No

Frequency of Counselling Service

Behaviour Therapy

Yes No

Behaviour Service

Are there restrictive practices?

Yes No

What are the restrictive Practices?

Delivery of services (*Travel fees apply per NDIS MMM Policy*)

Funding Options

Medicare Private Health Insurance Fee for Service NDIS

NDIS Budget

Type

Available Funding

NDIS Number

NDIS Start Date

Plan End Date

Do you consent to provide a copy of the NDIS plan?

Yes No

Upload NDIS Plan

Are there any risks we should be aware of ?

Yes No

If yes, please give details

Background Information / Reasoning for requested Supports / Behaviour of Concern

Face-to-Face Appointment Guidelines: You need to let us know if you or someone in your family have recently traveled overseas in the 14 days prior to our visit. If you are sick or unwell please reschedule your appointment. Your safety and that if our staff are important to us Please ensure to practice personal hygiene and social distancing measures.

I agree and will follow the guidelines upon Face-to-Face appointments

What happens next?

Once this referral is allocated to our Butter Fish Service team, we will make
contact to develop a Service Agreement or to confirm your first appointment.

REFERRAL FORM

Experience the Butter
Fish difference

Make A Referral

What happens next?

Talk to us today!

Company

Services

Contact Us

REFERRAL FORM

Experience the ButterFish difference

Make A Referral

What happens next?

Talk to us today!

Company

Services

Contact Us

Experience the Butter
Fish difference