Once submitted we will be in touch within 1-2 business days to offer you an appointment~

If you have any questions

email us at hello@projectmindset.com.au

or

call us on 08 7160 3598

We look forward to working with you!

Todays Date *

Your Details

First Name *

Preferred Name

Last Name *

Agency

Additional Relation to Client (If applicable)

Email Address *

Phone Number *

Best times to Contact you regarding this referralPlease input your ideal contact hours so we know when to try reaching you~

Client Details

Preferred Name

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Please contact my Support Coordinator/Representative/Guardian first

Please contact the Referrer prior to contacting the client.

Pronouns (Choose all that apply) *

She/HerHe/HimThey/ThemOther

Please feel free to include specifics in 'Identified Gender' field

Gender *Assigned at Birth

Identified GenderIf other than Assigned Gender

This person does not have a home address.

Input the Address that the person is known to spend majority of their time.

I do not have a home address

Please input the Address or Location you spend the majority of your time

Client Street Address *

City *

State *

Postcode *

Please include your known diagnoses (if applicable)

Funding Details

NDIS Participant

Medicare Mental Health Care Plan (MHCP)

Other

Government

Privately Funded

Other

Health Insurance ProviderIf Applicable

Health Insurance Policy Number *

Provider ABN

Agency / Department *

Do we need to be an approved Vendor/Provider with your specific Agency/Department?

Please tell us the details!who do we need to contact or what is the process to becoming an approved vendor so we can engage in services ASAP and get this done smoothly

Upload the application form or any documentation necessary

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If you have it on hand, uploading it here will allow us to review it and submit it sooner, or let you know if we have already been approved! If not you can send it to hello@projectmindset.com.au when you get a chance

Name of Funding Body *

Fund Management/Client Identifier *How is the client to be referenced for invoices? E.g. Client Name and DOB, DCS ID, Last name and NDIS Number, Etc.

I will pay by card on the day!

Invoice recipient *Who are we sending invoices to? First and Last name

Email *For Quote/Invoice/Receipt purposes

Contact Number

Medicare Details

Medicare Card Number *

Individual Reference Number [IRM] *What place are you on the card?

Medicare card Expiry Date *

Valid Mental Health Care Plan

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Please take a photo or upload the Mental Health Care Plan you have received from your GP/Doctor. Otherwise you can bring this with you to your first appointment, please come at least 10 minutes early.

A Claimant will be claiming the rebate from Medicare on behalf of the client.

Claimant Medicare Card Expiry Date *

Claimant Medicare Card Details *

Claimant Individual Reference Number [IRM] *What place are you on the card?

What is your relation to the MHCP holder? *

I understand that for my rebate to be claimed, payment must be made on the same day as service provision. *

NDIS Details

NDIS Number *

Plan Start Date *

Plan Review Date *

What is the primary diagnosis? *

What are the additional diagnoses? (If any)

Plan *

Plan Managed Self Managed Agency Managed

Specifically the participants Capacity Building budget

Plan Manager Name *

Plan Manager Agency *

Plan Agency *

PACEPRODA

NDIS approved persons will call the NDIA (1800 800 110) to endorse Project Mindset Pty Ltd to claim for payment on PACE prior to the commencement of services *

Plan Manager Contact Number *

Plan Manager Email *For invoicing purposes

There is a specific/limited amount of funding available for this referral in the participants current plan.

What funding is available?Capacity Building - Improved Daily Living // Psychology

NDIS Goals (As stated in the NDIS Plan)Please attach plan or fill out here - if you do not have it on hand, please send it to hello@projectmindset.com.au at your earliest convenience.

NDIS Plan

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Psychology Services

Other Referral Reason *

Other Neuropsychological Capacity Assessment Reason *

Queried Diagnosis *

Please provide some additional information for the referral reason as indicated above *

The participant has a pre-existing BSP practitioner or plan

Additional File Upload

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Additional information is really helpful to your clinicians, you may choose to bring this to your first appointment, this might include prior reports, assessments

Appointment Preferences

Please note that these are preferences, while we will try our best to accomodate, there may be cases we are unable to.

There are ideal appointment times to promote engagement, and I understand that Project Mindset will try their best to adhere to these however may not be able.

Morning (0900 - 1100) Midday (1100 - 1400) Afternoon (1500 - 1700) Flexible

Project Mindset's operating hours are from Monday to Friday between 0900 - 1700 (9am to 5pm) ACST

Project Mindset are proud to also support clients in Rural and Remote South Australia!

Let us know where you are requesting services.

Requesting appointments in Rural and Remote South Australia

Appointments will be held at the Project Mindset Office

Appointments to be held via Telehealth

Appointments will be held offsite.

Telehealth Format *

Video CallPhone CallOther

Other *

There are stairs to attend the Project Mindset Office, if the client or any others expected to be present are unable to traverse stairs, please reach out to confirm alternative options.

Project Mindset hold Telehealth Appointments via Zoom - if you have another preferred format please choose 'Other' to advise.

Stable internet connection is required, it is not ideal to have Video Call Appointment/s on a mobile device, please ensure there is an appropriate device readily available for appointment organisation.

Requested Appointments same as Client Home Address

Requested Appointment Address *

Street address *Street address line 2

City *

State *

Postcode *

Ensure there is an appropriate private space for appointments to be held? Please ensure the Premise is easily accessible from the street and advise if there are any environmental risks to be taken into account.

Information on the requested appointment location *Does Project Mindset need to contact staff there to organise appointments? How does the clinician contact/inform people when they arrive to this location? What are any potential hazards or aspects to note about this requested location? Will there be animals/pets present? Anything else we should know?

Contacts

There must be at least 1 emergency contact

First Name *

Last Name *

Phone Number *

Email *

Specific Relationship to Client *

Emergency Contact Address *

Street address *

City *

State *

Postcode *

Add another contact

First Name *

Last Name *

Phone Number *

Email

Specific Relationship to Client *

Emergency Contact Address *

Street address *

City *

State *

Postcode *

Add another contact

First Name *

Last Name *

Phone Number *

Email

Specific Relationship to Client *

Emergency Contact Address *

Street address *

City *

State *

Postcode *

Add Additional Contacts

Additional Contact Details *

I have obtained consent to provide the contacts details and they are aware that they may be contacted as per the above referral. *

I consent to providing my information and for Project Mindset to reach out to necessary contacts as per the referral form provided *

I have obtained consent to complete the referral form on behalf of the client or their guardian and understand that Project Mindset Pty Ltd are a registered NDIS provider and will reach out to relevant contacts as per the completed referral form. *

Please referrer to our Privacy Policy found on www.Projectmindset.com.au/PrivacyPolicy for all information regarding how we handle your information

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NDIS Number: 4050107648

ABN: 25 644 321 684