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About
- About us
- Blog
Services
Locations
Careers
- Award winning graduate program
- Join the team
Payment
Make a referral
Enquire now

NDIS referral

Make a referral to Mobile Rehab. Use this form to refer clients for services under the National Disability Insurance Scheme (NDIS).

Make an NDIS referral

NDIS referral form

"*" indicates required fields

Referrer information

Relationship*

Participant

Relative/advocate

Support coordinator

Organisation

First name*

Last name*

Phone number 1*

Phone number 2

Email*

Preferred method of contact

Phone

Participant information

Pronoun

First name*

Last name*

Date of birth*

Day

Month

Year

Phone number 1*

Phone number 2

Address*

Street Address Suburb State Postcode

Are we able to consent with the participant?*

Are we able to send service agreements to the participant?*

Address for service agreements*

Street Address Suburb State Postcode

Best contact to arrange appointments

Specific requirements for appointments

Plan details

Plan goals

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

NDIS participant number

Plan dates

How is this Plan managed?

Plan nominee

First name

Last name

Phone number

Next of Kin / Enduring Power of Attorney (EPOA) / Public Guardian

First name

Last name

Relationship

Phone number 1

Phone number 2

Type of relationship*

Plan manager

First name

Last name

Organisation name

Phone number

Service request

Physiotherapy

Occupational therapy

Exercise physiology

Dietetics

Podiatry

Physiotherapy service

Funding category

Any previous provider?

Handover provided?

Yes

Occupational therapy service

Funding category

Any previous provider?

Handover provided?

Yes

Exercise physiology service

Funding category

Any previous provider?

Handover provided?

Yes

Dietetics service

Funding category

Any previous provider?

Handover provided?

Yes

Podiatry service

Funding category

Any previous provider?

Handover provided?

Yes

Other information

Does this client have a Positive Behaviour Support Plan?*

If yes, please provide Mobile Rehab with a copy and please note a known carer needs to be present at initial appointment.

Positive Behaviour Support Plan*

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

Medical history

Reason for referral

Additional documents and information

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB.

Comments

This field is for validation purposes and should be left unchanged.

Mobile Rehab Australia
ABN 46 601 467 529
PO Box 192
Grange QLD 4051

Mon - Fri, 7:30am - 5:00pm

1300 363 483

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Mobile Rehab acknowledges the Traditional Owners of Country throughout Australia and recognises their continuing connection to land, waters, and communities. We pay our respects to Aboriginal and Torres Strait Islander cultures and to Elders past, present, and emerging. We are committed to creating a safe, inclusive environment for all, embracing cultural and linguistic diversity (CALD) among our employees and clients. As proud allies of the LGBTQIA+ community, we foster an atmosphere of respect, support, and equality.