Capacity Enquiry and Referral Form

Date of referral *

Is this a Capacity Enquiry for Services? *

If you have submitted an Enquiry that has been accepted, you have been directed back to this page to complete the Full Referral. Please change the dropdown option of "Is this a Capacity Enquiry" to "No - specific Referral" .

The notes on accepting this Enquiry to become a Referral from our Manager are:

{{capacity notes to referrer}}

You have been directed back to this Referral to add or amend the information required as per these notes from our Manager:

{{please describe what further info is required from referrer}}

Please note - Completion of this Enquiry/Referral form does not guarantee that it will be accepted.

Client Details

First Name *

Last Name *

Date of Birth *

Gender *

FemaleMaleOther/Non Binary

Please provide pronouns

Email *

Phone Number *

Address *

Cultural Considerations

Is this person under the care of a Public Guardian? *

YesNo

Guardianship information (name and contact details) *

Client Representative / Plan Nominee

First Name

Last Name

Relationship to Client

Contact Phone Number

Email

The Client Representative/Plan Nominee is to be listed as an Emergency Contact

If there is an Advocate in place, please specify their information below

Advocate name, contact details and organisation

Capacity Enquiry

Name of Person *

Location (Suburb and State) *

Age of Person *

Cultural Considerations

IMPORTANT

This Client has a Public Guardian or Advocate

Public Guardian and or Advocate - Name and contact information *

Please describe the situation and how the referral reason impacts quality of life for this Client at this time *

Please provide information regarding required services and any time frames for deliverables this Client may need *

Please advise the ideal time frame for services *

Enquiry Funding Category *

NDISPrivate

$ Amount Available for Private *

NDIS Funding Allocations *

Please advise any general risk to visiting the Person or at initial appointment *

Any documents that might support this enquiry?

Browse

Enquirer Name *

Enquirer Phone

Enquirer Email *

Referrer details

First Name *

Last Name *

Referral Organisation

Referrer's relationship to Person *

Other relationship

Referrer Phone *

Referrer Email *

The person being referred has given consent to this referral and consents to these details being kept on a cloud based case management system *

Referral Reason

Referral Concerns: What would you like support with? *

Please describe the situation and how the referral reason impacts quality of life for this Client at this time *

Diagnosis of Person requiring services *

Please provide information regarding time frames for deliverables this Client may need *

Funding Information

Funding Type *

National Disability Insurance Scheme (NDIS)Privately Funded

NDIS Number *

Plan Start Date *

Plan End Date *

Funding Source *

NDIA ManagedPlan ManagedSelf Managed

As this is an Agency Managed referral - The Referrer agrees to work with the Client/Client's Representative to endorse LeadsCare Services in PACE. Our NDIS Registration Number is: 4050137774 *

Plan Manager *Please provide Company name

Send invoice to: *Please add email address

Please make sure to provide the correct budget details.

If there are any uncertainties, we will contact you via email to confirm the breakdown of the funding line items.

It is important to note that incorrect financial information may prevent the referral from being processed.
Non-labour travel is charged at $1.00/km and is not included in the hours below.

Support Worker Hours available *Price varies for supports depending on day and time delivered - see table below

Support Worker Minimum DollarsPlease note this is an approximation only

Please note this is an estimate on Support Worker funding as there may be Evening, Overnight, Weekend or Public Holiday supports required, which is a different rate to Daytime services.

Assistance With Self-Care Activities:

Support Category Name	Line Item	Rate per hour
Standard - Weekday Daytime	01_011_0107_1_1	$67.56
Standard - Weekday Evening	01_015_0107_1_1	$74.44
Standard - Weekday Night	01_002_0107_1_1	$75.82
Night-Time Sleepover	01_010_0107_1_1	$286.56
Standard - Saturday	01_013_0107_1_1	$95.07
Standard - Sunday	01_014_0107_1_1	$122.59
Standard - Public Holiday	01_012_0107_1_1	$150.10

Registered Nurse Hours Available *Price varies for supports depending on day and time delivered - see table below

Registered Nurse Minimum DollarsPlease note this is an approximation only

Please note this is an estimate on Registered Nurse funding amount as there may be Evening, Weekend or Public Holiday supports required, which is a different rate to Daytime services.

CORE: Delivery of Health Supports by a Registered Nurse:

Support Category Name	Line Item	Rate per hour
Weekday Daytime	01_606_0114_1_1	$119.82
Weekday Evening	01_607_0114_1_1	$132.18
Weekday Night	01_611_0114_1_1	$134.64
Saturday	01_608_0114_1_1	$171.00
Sunday	01_609_0114_1_1	$196.58
Public Holiday	01_610_0114_1_1	$222.16

Please note this is an estimate on Registered Nurse funding amount as there may be Evening, Weekend or Public Holiday supports required, which is a different rate to Daytime services.

CB Daily - Community Nursing Care: Delivery of Health Supports by a Registered Nurse:

Support Category Name	Line Item	Rate per hour
Weekday Daytime	15_406_0114_1_3	$119.82
Weekday Evening	15_407_0114_1_3	$132.18
Weekday Night	15_411_0114_1_3	$134.64
Saturday	15_408_0114_1_3	$171.00
Sunday	15_409_0114_1_3	$196.58
Public Holiday	15_410_0114_1_3	$222.16

Clinical Nurse Hours Available *Price varies for supports depending on day and time delivered - see table below

Clinical Nurse Minimum DollarsPlease note this is an approximation only

Please note this is an estimate on Clinical Nurse funding amount as there may be Evening, Weekend or Public Holiday supports required, which is a different rate to Daytime services.

CB Daily - Community Nursing Care: Delivery of Health Supports by a Clinical Nurse:

Support Category Name	Line Item	Rate per hour
Weekday Daytime	15_412_0114_1_3	$138.60
Weekday Evening	15_413_0114_1_3	$152.88
Weekday Night	15_417_0114_1_3	$155.75
Saturday	15_414_0114_1_3	$197.79
Sunday	15_415_0114_1_3	$227.39
Public Holiday	15_416_0114_1_3	$256.98

Specialist Hours *$222.99 per hour

Specialist Dollars

Management Plan (Standard) Hours *$222.99 per hour

Management Plan (Standard) Dollars

Social Skills Hours *$77.00 per hour

Social Skills Dollars

Social Worker Hours *$193.99 per hour

Social Worker Dollars

Occupational Therapist Hours *$193.99 per hour

Occupational Therapist Dollars

Other Therapy Hours *$193.99 per hour

Other Therapy Dollars

CORE Hours *$193.99 per hour

CORE Dollars

If CORE Other Therapy Supports are to be used - please provide evidence of approval *Specific consent from the LAC for this Client must be provided before LeadsCare Services can claim from CORE Other Therapy Supports.

Total Hours

Total Dollars

Budget in $ for Private *If unknown, please provide an estimated $ amount of the next 12 months

Any other funding information?

Send Service Agreement to *

Contact for arranging appointments *

If the Client consents, please upload a copy of the NDIS Plan if able

Browse

NDIS Plan Goals *

Any reports or documents that may assist with Services for the Client

Browse

Complaints & Feedback

Do you have any complaints or feedback you would like to share with us? Click Here to submit your feedback to Billy Cart Behaviour.

Risk Factors

Please provide information about risks to the Person, Community, Family, Environment or Therapists.

If you have answered yes or unsure to any of the above questions, please include more information here *Please provide explanation in as much depth as possible

Capacity to Enquiry

This Person is suitable for Referral *

Yes - send referral back with "please complete"No - send polite declineNeeds liaising with Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Capacity Notes to Referrer *PLEASE write in here your yes no or maybe reasoning, and this is auto sent to the Enquirer on workflow emails

Thank you - this Referral form will be sent back to the Enquirer

Name of Enquirer

Liaise via Phone

Liaise via Email

Referral Information

Deliverables

Behaviour Support PlanOccupational Therapy ReportSupport Work ReportOther

If Other, please specify *

Medications *

Are there other Stakeholders Involved in care *

YesNo

Please provide any relevant Documents or Reports

Browse

Please explain any identified Restrictive Practices in use *

Stakeholder(s) Involved

How many Stakeholders are involved? *

1st Company

Name

Phone

Email

Position

2nd Company

Name

Phone

Email

Position

3rd Company

Name

Phone

Email

Position

2nd Company

Name

Phone

Email

Position

3rd Company

Name

Phone

Email

Position

4th Company

Name

Phone

Email

Position

Any other Contacts?

Director Review

This Person is suitable for services *

YesYes - WaitlistedNoNeed further info

ADMIN: Yes is always Yes - Waitlisted unless otherwise specified in Director Finalisation: "Any specifics re wait time for this particular Client?"

Please describe what further info is required from referrer *Please be aware this text is sent to referrer on the workflow email

If No, please specify why the decline of acceptance *

Any further information

Allocated Therapist *

Therapist Email *

Director Finalisation

Communication method for waitlist notification *

EmailSMSCall

Any specifics re wait time for this particular Client? *

Next Steps *

Admin setup case file in Splose

Admin send SA - please advise below:

Ongoing Support hours or dollars for SA *

Private - Support hours or dollars for the Case Budget *

Rate for Private Services *

$193.99$222.99Other

Private - Other Rate *

Any further notes or info

Admin Actions

Setup Client in Splose and add tag 'Unsigned SA' - if no Client own phone or email please enter the Rep's details in these fields so as to prompt reminders - both "SMS & Email" *

Setup Client in Asana and add Pending SSA Tag *

Add Therapist to Client profile in Asana *

Add Therapist tag in Splose *

Risk in Splose Alert box (if any noted) *

Billing type in Alert Box (e.g. Specialist, Standard, Skills, OT, RN) and Client Tags *

Funds management tag in Splose - Private, Self, Plan or NDIA *

specified Rate per hours for Private Services

$193.99/h please use the "Bill: Private $193.99" and "Private" tags *

$222.99/h please use the "Bill: Private $222.99" and "Private" tags *

please use the "Bill: Private Other $/h see ALERT" tag and notate the $/h in the Alert Box *

Reason for Referral, SC and NOK details added to 'Other Details' during Splose setup *

Referrer and any other identified contacts added in to Client Contacts in Splose *

Medications (if any), Diagnosis & Plan management type in Splose *

NDIS Number and Plan dates added into NDIS fields *

Add "Send invoices to" in Splose - leave blank/rep if SM, PM for PM, NDIA for NDIA

Add "Send invoices to" in Splose - leave blank or add Rep or 3rd Party as per "Send invoice to" field above

Invoice reminders turned on in Splose *

Add Waitlisted Tag on client profile in Splose and add Waitlist tag on Asana - move client to Waitlist Section on LeadsCare Asana

Add Client to Waitlist Section in Splose, add therapist if known and select M-F am-pm

Communication type for waitlist notify

Created and assigned Asana task and notified in Slack channel - for Annie to call/text this client *

This Client will receive Support Work OR Registered Nursing OR Clinical Nursing
In regards to shift times the following applies:
Day shift - 6am until 8pm
Evening - 8pm until 10pm
Night - 10pm until 6am next day

1. Please fill in this Excel sheet based on the information provided from the Directors,
LEADS Quoting Calculations Spreadsheet (click me) or found in PPM OneDrive

2. Right click on either the Support Work or Registered Nursing or Clinical Nursing TEMPLATE tab you wish to copy and choose "Move or Copy" check the box "Create a copy"
3. Right click again on the new tab you just created from the Template, choose "Rename" and change to "LASTNAME First and prefix SW or RN or CN"
4. Add in: Participant Name, NDIS Number, Service Start date (as specified by M&T) and Plan End date (NDIS)
5. Add in Transport section: insert the "Maximum km/day" in column B, just number form (no km suffix)
6. Use the information from M&T about shifts to enter into column H.
Please use info above re timing of shifts and check the examples below

Info from Molly & Tinashe	Equates to this data for the Quoting Calcs Spreadsheet
Tuesdays 9am to 12pm and then 4pm to 7pm Wednesdays 7am to 9am and then 3pm to 6pm Fridays 7am to 9am and then 3pm to 6pm Saturdays 9am to 3pm Transport- 0.97c / kilometre.	Tuesdays - 6 hours day shift Wednesdays - 5 hours day shift Fridays - 5 hours day shift Saturdays - 6 hours day shift Transport - "as required" and alter the column C to be "0.97"
Monday 6am to 10am and 8pm to 9pm	Monday - 4 hours day shift, 1h evening
Friday 7pm to 8am Saturday	Friday - 1 hour day shift, 2 hour evening, 8 hour night Saturday - 2 hour day shift

CHECK WITH ANNIE IF UNSURE

7. Click and drag from cell A1 to the bottom corner of the Sheet J37 - Go up to File - Print - Settings Print Selection "Only print the current selection" and use your Print to PDF on your computer.
8. Upload the PDF to Splose "LASTNAME Firstname LCS Quoted Schedule of Supports"
9. and keep the PDF handy as you will need to upload it into the Service Agreement also

Case Budget Setup in Splose
(If this is a SW or RN or CN Client - create different cases for total day shifts, evenings and nights as per the calculations just performed)
* Please title SURNAME - dd.mm.yy-dd.mm.yy - Please split by Category and add the suffix
* Type: Hours
* Referral type - Non standard: start date will be date of referral and end date will be end of plan
* Case Alert Reminder - 4 weeks, 70% used, Add Therapist *

NDIS Service Agreement (link - click here)

Set up and Send SA to Client/Representative/Guardian

SA to be sent to

NDIS Funding Category/s

{{funding allocations}}

The link for the SA will come through the workflow email from SA SF "ACTION NOTE: Service Agreement for"

Comment on the Asana client profile as 'SA Sent for signing dd.mm.yy - (link to SA)' and create a follow up subtask for review each 7 days until returned

Add the (link to SA) as 'Unsigned SA' in Alerts Section of Splose with tag

If this is a Private Referral then NO SA is to be sent

Upload documents and this completed referral to Splose when the workflow email comes through post completion *

Admin Completing this Form *

Save and Complete Later