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}}

We are dedicated to Closing the Gap and improving health outcomes for Aboriginal and Torres Strait Islander peoples. We strive to build strong, culturally safe partnerships with local Aboriginal communities, organisations, and health services.

We are committed to providing culturally safe, respectful services and creating a welcoming environment for Aboriginal and Torres Strait Islander individuals, their families, and communities. We also support and value Aboriginal and Torres Strait Islander people within our workforce.

Our service is firmly committed to eliminating all forms of racism and ensuring equitable access to healthcare, contributing to better health outcomes for Aboriginal and Torres Strait Islander peoples.

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 *

Improved Relationships Improved Daily LivingCORE Assistance with Daily Life AND/OR Assistance with Social, Economic and Community ParticipationUnsure - Need to provide NDIS Plan and discuss with Admin

Has this Plan been received on or after 19 May 2025? *

YesNo

With the introduction of funding periods and components in NDIS Plans, we now require confirmation of the hours available for each funding period. This helps us align our services with the Plan's structure and ensures continuity of support.
If this Enquiry progresses to Referral, please have this information available.

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 *

Has this Plan been received on or after 19 May 2025? *

YesNo

With the introduction of funding periods and components in NDIS Plans, we now require confirmation of the hours available for each funding period. This helps us align our services with the Plan's structure and ensures continuity of support.

Any unused hours within a funding period, LeadsCare will automatically roll over and apply to the next funding period to ensure continuation of services.

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

LeadsCare Services offers the following support types:

Group	Category	*Item Name*	Item Code	Price per hr (MMM1-5)	*Commonly known as*
Improved Relationships	Behaviour	Specialist Behaviour Intervention Supports	11_022_0110_7_3	$222.99	“Specialist”
Improved Relationships	Behaviour	Behaviour Management Plan and Training	11_023_0110_7_3	$222.99	"Standard"
Improved Relationships	Relationships	Individual Social Skills Development	11_024_0117_7_3	$77.00	"Skills"
Capacity Building	Improved Daily Living	Social Worker	15_621_0128_1_3	$193.99	“Social Work”
Capacity Building	Improved Daily Living	Occupational Therapy	15_617_0128_1_3	$193.99	“OT”
Capacity Building	Improved Daily Living	Other Therapy	15_056_0128_1_3	$193.99	“Other”
Capacity Building	Improved Daily Living	Therapy Assistant Level 2	15_053_0128_1_3	$86.79	“TA2”
Capacity Building	Community Nursing Care	Registered Nurse	Various line items from 15_406 up to 15_411_0114_1_3	Varies	“CBDaily RN”
Capacity Building	Community Nursing Care	Clinical Nurse	Various line items from 15_412 up to 15_417_0114_1_3	Varies	“CBDaily CN”
CORE	Community Nursing Care	Registered Nurse	Various line items from 01_606 up to 01_611_0114_1_1	Varies	“CORE RN”
CORE	Assistance with Daily Life	Support Work	Various line items from 01_002, 01_010 up to 01_015_0107_1_1	Varies	“Support Work”
CORE	Assistance with Social, Economic and Community Participation	Access Community: Support Work	Various line items from 04_102 up to 04_106_0125_6_1	Varies	“Community Support Work”

I need further information about the varying line items and rates for:

CORE - 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

CORE - Assistance With Social, Economic and Community Participation: Access Community:

Support Category Name	Line Item	Rate per hour
Standard - Weekday Daytime	04_104_0125_6_1	$67.56
Standard - Weekday Evening	04_103_0125_6_1	$74.44
Standard - Saturday	04_105_0125_6_1	$95.07
Standard - Sunday	04_106_0125_6_1	$122.59
Standard - Public Holiday	04_102_0125_6_1	$150.10

We may also provide services under - CORE - Assistance with Daily Life:

Support Category Name	Line Item	Rate per hour
Assistance with Personal Domestic Activities	01_004_0107_1_1	$57.23
House Cleaning And Other Household Activities	01_020_0120_1_1	$56.23
STA and Assistance (Inc. Respite) 1:1 - Weekday	01_058_0115_1_1	24h/d $2,098.80

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

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

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 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.

Please enter ALL funding periods below, with the allocation of dollars for LeadsCare Services, and type of service required (see table above - column "Commonly known as").

If there are multiple services required, please start a new line for each service, so that the dollar allocation is accurate.

If the NDIS Plan is the old lump sum format, please enter the Plan Start and End dates, along with dollar allocation and type of service required below (see table above - column "Commonly known as") .

If there are multiple services required, please start a new line for each service, so that the dollar allocation is accurate.

Start Date for funding period *

End Date for funding period *

$ Amount to be allocated *

Service required *

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 LeadsCare Services.

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

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 Service Agreement - please advise below:

Ongoing Support hours or dollars for SA *

Private - Support hours or dollars for the Case Budget *

Rate for Private Services *

$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 in ENQUIRIES Section and add Pending SSA Tag *

Add Therapist to Client profile in Asana *

Add Therapist tag in Splose *

Add PTG tag if req (OPG/PTG/DCJ/QCAT etc)

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

Add to Alert box "Bill: Private $222.99" and "Private" tag *

Add to Alert box "Bill: Private $XX" being $/h specified and "Private" tag *

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 *

In Splose: add Waitlisted Tag on client profile in Splose. In Asana: chose Enquiry dropdown (pre SSA return) and add "⏸️waiting for SA" next to name

Add Client to Waitlist Section in Splose, choose service, add therapist, select M-F am-pm, add in "⭐Unsigned SA" to the Waitlist Notes box

Communication type for waitlist notify

Created and assigned Asana task and notified in MS Teams channel - for Annie to call or 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 LEADS Quoted Schedule of Supports dd.mm.yy" where dd.mm.yy is start of SA
9. and keep the PDF handy as you will need to upload it into the Service Agreement also

Support Work Client added to ShiftCare - click here review the setup of the current Clients to copy and click here for the how to.

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

If this is an S33 Plan - please create Cases for each funding period labelled Period X: Surname dd.mm.yy - dd.mm.yy using the date (and number) of the Period rather than overall Plan dates. *

NDIS Service Agreement (link - click here)

Set up (Start date is DATE OF REFERRAL) and Send SA to Client/Representative

If this is an OPG Client do NOT put their specific email address in Authorised Representative email field, JUST LEAVE BLANK, and put n/a for Client email. Make sure you include the SC email in the SC email field.

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