NDIS referral

Make a referral

Refer yourself or someone you support for NDIS Support Coordination (Level 2) or Specialist Support Coordination (Level 3) in the Northern Territory. We'll be in touch to talk about next steps.

Before you start: please make sure the participant knows about and agrees to this referral. We can currently support participants whose Support Coordination funding is self-managed or plan-managed (not NDIA-managed). Fields marked "required" must be completed. If you'd rather talk it through, call our Support Coordination line on 0478 782 904 or email support@leadwiseconnect.com.au.

Don't fill this out if you're human:

1 Referrer details

Are you the participant? Yes, I'm referring myself No, I'm referring someone else

Your name (required)

Relationship to participant / role

Organisation (if applicable)

Phone (required)

Email (required)

2 Participant details

Participant's full name (required)

Date of birth

Participant's phone

Participant's email

Suburb or community (required)

NDIS number (optional)

Best way to contact the participant

Communication or cultural needs

3 NDIS plan and support needed

Plan start date

Plan end / reassessment date

Support level needed (required) Level 2 – Support Coordination Level 3 – Specialist Support Coordination Not sure

How is the plan managed?

We can currently support self-managed or plan-managed Support Coordination funding. We're not able to support NDIA-managed (agency-managed) plans at this time. If you're not sure, choose "Not sure" and we'll help you check.

Reason for referral and the participant's goals (required)

Anything we should know to keep everyone safe?

4 Consent

By submitting, you agree to our Collection notice and Privacy policy.

Please don't use this form for urgent or emergency situations. In an emergency, call 000.