Referral & Registration Form

If you would like to register for one of our services, please complete the online form below. A member of our team will then be in touch with you to discuss the services you would like to access and their availability. If you have any questions around our current capacity, please feel free to call our office on 08 7085 3999.
Disclaimer*
By checking this box you acknowledge that I Can Jump Puddles collects the following information to assist in determining if we are able to provide you with the supports enquired. More details on how we store and what we do with your information can be found in our Privacy policy under the 'Resources' tab on our website.

Are you a new or existing client?*
- New
- Existing

Are you an NDIS participant?*

Funding Type*
- NDIS
- Private
- Medicare
- DCP
- Other
DCP Office Address*
Medicare Plan*
Max. file size: 128 MB.

Primary Contact
Is this person a legal guardian of the client?*
Name*
First Last
Email*
Phone*
Relationship to Client*

Medical Details
Do you identify with a disability?
Health
Primary Disability*
Secondary Disability*
Autism Level*
Other, please specify:
Health Continued
Other Medical/Health Conditions
Mental Health Conditions
Medications
Vision*
Aids Or Equipment Used / Other Information - Vision
Hearing*
Aids Or Equipment Used / Other Information - Hearing
Communication*
Aids Or Equipment Used / Other Information - Communication
Mobility*
Aids Or Equipment Used / Other Information - Mobility
Medical Reports, Medication Summaries You Would Like To Upload
Drop files here or

Max. file size: 128 MB.

Client Demographics
Country of Birth*
Main Language Spoken at Home*
Do you require an interpreter?*
- Yes
- No
Interpreter Details*
Indigenous Status*
- Aboriginal but not Torres Strait Islander Origin
- Torres Strait Islander but not Aboriginal Origin
- Both Aboriginal and Torres Strait Islander Origin
- Neither Aboriginal nor Torres Strait Islander Origin
- Declined to Answer

NDIS Plan
Start Date*
DD slash MM slash YYYY
End Date*
DD slash MM slash YYYY
Funding Management*
- NDIA Managed
- Plan Managed
- Self-Managed
Plan Management Company*
Email address for invoices
Please upload NDIS Plan
Max. file size: 128 MB.

Risk
Any risks/safety concerns we should be aware of?

Client Details
Client Full Name*
NDIS Number*

Support Coordination
Supports Required - Support Coordination*
- Housing
- Transitioning Out of School
- First NDIS Plan
- Justice
Funding Allocated - Support Coordination
Additional Comments - Support Coordination

Specialist Support Coordination
Supports Required? (SSC)*
- First NDIS Plan
- Housing
- Justice
- Transitioning Out of Hospital
- Transitioning Out of School
Funding Allocated (SSC)
Additional Comments (SSC)

Social Work
What are the participant's goals for Social Work support?*
What type of support(s) do you require? (Tick box as required)*
Please Choose*
- Assessment
- Consult
Where is the preferred location of support?*
How many hours of support are required (if known)?
Additional comments

I Can Exercise
Please select a session to attend - I Can Exercise*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Play Sport
Please select a session to attend - I Can Play*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Explore
Please select a session to attend - I Can Explore*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Cook
Please select a session to attend - I Can Cook*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Relax
Please select a session to attend - I Can Relax*
If you can't make all sessions, please contact our admin team
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Create
Please select a session to attend - I Can Create*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*

I Can Ride
Please select a session to attend - I Can Ride*
Who will be accompanying the client to the session?*
Are there any risks or concerns with group participation (e.g. behavioural concerns, mobility needs etc.)?*
What bike/scooter will the client be bringing to the session?*

I Can Thrive
Session*
What is the client's age?*
Who in your family will be participating in the group?*
When is your child due to start school?*
Do you know what school your child would likely attend?*
Does your child currently attend Kindy or preschool? Which preschool or kindy?*
How are you feeling about your child starting school?*
Accessibility needs to support getting to the sessions safely?*
Medical alerts/allergies*
What would you like to get out of the group?*
Do you have any concerns about your child starting school?*
What best helps your child to thrive?*
What might limit your child's participation in a family group setting?*

Child Voice
Session
What would you like to get out of the session?
Who will be attending the session?
Do you require child-minding services?
Specific Support Needs to Consider
Please elaborate if needed

Assistive Technology Consultation
Preferred Date*
What NDIS goals would you like to achieve with the assistive technology?*
What is your budget for purchasing equipment?*
What type of assistive technology are you looking for? (e.g. crash mats, small fidgets, gross motor equipment, visual schedules, sensory tent etc.)*
Do you have equipment at home you find helps you to regulate or you enjoy using? This will help us with selecting the correct equipment to trial.*

Therapy Assistant
Therapist Name*
Frequency + Day/Time - Please give at least 3 options (otherwise follow up is required)*
Length of each session*
Location of session (suburb + school/home/childcare etc.)*
Length of program (No. of weeks)*
Would the client be interested in participating in school holiday groups?
- Yes
- No
What the client be interested in receiving 1:1 supports in the school holidays?
- Yes
- No
Additional Information
TA Program (File needs to contain TA Program in its file name)*
Max. file size: 128 MB.

Functional Capacity Assessment
What is the purpose of this functional capacity assessment?*
When does this functional capacity assessment need to be completed by?*
DD slash MM slash YYYY
What support do you require?*
- Independent living skills e.g. self-care, independent living skills, safety skills
- Relationship/social skills
- Self-regulation skills/understanding emotions
- Building self-esteem: Transitioning program e.g. to school
- Other
Where is the preferred location of support?*
- Home
- School
- Work
How many hours of functional capacity assessment required if known?

Training Packages
Please elaborate on what is required*

Payment
I Can Cook
Price:
I Can Create
Price:
I Can Explore
Price:
I Can Ride
Price:
I Can Relax
Price:
I Can Play
Price:
Total
$ 0.00
Credit Card*
Card Details
Cardholder Name

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

Step 1 of 42

Services for Request

Preferred Days and Times

Client Details

Primary Contact

Medical Details

Health

Health Continued

Client Demographics

NDIS Plan

Safety

Risk

Client Details

Support Coordination

Specialist Support Coordination

Developmental Education

Physiotherapy

Dietetics

Counselling

Occupational Therapy

Positive Behaviour Support

Speech Therapy

Early Childhood Intervention

Social Work

Hydrotherapy/I Can Splash

Epilepsy / Seizures

Asthma

Anaphylaxis / Allergies

About You (Communication Skills)

About You (Behaviour of Concern)

About You (Mobility)

Hydrotherapy Program

I Can Exercise

I Can Play Sport

I Can Explore

I Can Cook

I Can Relax

I Can Create

I Can Ride

I Can Thrive

Child Voice

Assistive Technology Consultation

Therapy Assistant

Functional Capacity Assessment

Training Packages

Referrer Details

Payment