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SIL Referral Form

Complete this referral form and submit it to start participant intake.

1. Referrer Details

2. Participant Details

Interpreter Required

Preferred Communication

Aboriginal and/ or Torres Strait Islander

3. Participant Representative

Guardianship / Administration / Plan Nominee Order in Place?
Relationship
Primary Carer?
Lives with Participant?
Emergency Contact

4. Funding Details

SIL Eligibility Confirmed in Plan?
If SIL eligibility is not confirmed, is a change of circumstances or review in progress?
Plan Management Type
Funding Ratio (Staff:Participant)

Plan Manager Details

5. Disability, Health & Behaviour Summary

Health Conditions and Behaviours of Concern

Support Intensity

Support intensity refers to the level of support identified in the participant's NDIS plan, not the complexity of the person.

Health Conditions

Behaviours of Concern (if any)

Regulated Restrictive Practices

Are any NDIS Regulated Restrictive Practices currently in place or proposed?

If Yes or Proposed, please indicate type(s):

Existing Documents Available

6. Support Needs Overview

Communication Method (select all that apply)

Day Support

Can be alone for short periods (1-2 hours)?
Can be alone for longer periods (3+ hours)?

Night Support

If active night support is needed, select reasons:

Mobility & Equipment

Please describe the participant's mobility and any equipment used (e.g. wheelchair, hoist, walking frame). Can the participant safely mobilise up and down steps?

7. Current Situation

Current Living Arrangement

Describe the participant's current living arrangement (e.g. with family, current SIL, SDA, SRS, nursing home, hospital, temporary accommodation, other).

Current Supports

What formal and informal supports does the participant currently receive? Include service providers, family support, and community access.

Day Program / Community Access

Does the participant attend a day program or have established community access?
Is Myxa required to provide Community Participation (CP) supports in addition to Supported Independent Living (SIL)?

8. Matching & Housing Preferences

Living arrangement requirements

Describe the participant's current living arrangement (e.g. with family, current SIL, SDA, SRS, nursing home, hospital, temporary accommodation, other).

Cultural Requirements

Housing Considerations

Required Accommodation

Location Preferences

Staff Gender Preference

Myxa