Make a Referral

Straightforward referrals.
Fast responses.
Real follow-through.

Complete the form below to refer a participant to Human First. We respond to all referrals within one business day and will follow up with you directly before any placement is confirmed. If you'd prefer to talk it through first, call Alex on 0408 171 558.

Section 1 — Referring Party

Your details as the person making this referral.

Full name *

Company / Organisation *

Your role *

Phone *

Email *

Section 2 — Participant Details

Information about the person being referred.

First name *

Last name *

Date of birth *

Gender

Participant phone

Residential address *

Location / Service region *

Ballarat & Greater Regions Geelong & Surf Coast Other regional Victoria

Emergency contact — name *

Emergency contact — phone *

NDIS number *

NDIS plan start date *

NDIS plan end date *

Section 3 — Medical & Support Information

Help us understand the participant's needs before our first conversation.

Primary diagnosis / list of disabilities *

Does the participant require medication assistance? *

Yes No Unsure

Does the participant have any mobility issues? *

Yes No Unsure

Are there any risks we need to be aware of?

What would you like supports to focus on? *

Participant's NDIS plan goals *

Participant summary *

Preferred meet and greet

Section 4 — Support Preferences

Help us match the right worker to the right participant.

Worker gender preference

Worker age preference

Preferred days and times for support

Are travel time and kilometre charges approved in addition to support hours? *

Yes No Unsure

Are there any restrictions on travel?

Section 5 — Funding Information

Details needed to set up a service agreement.

Plan manager name *

Plan manager email / contact *

Funding allocation *

Line items to be used

Section 6 — Service Agreement & Submission

Service agreement email address *

Where should we send the service agreement once the referral is confirmed?

I confirm the above information is accurate and I have authority to make this referral.

Referral received.

Thank you — your referral has been received. Alex will be in touch within one business day.

Need to reach us sooner? Call 0408 171 558.