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SASS-able Referral Form
Complete this form to register with SASS Care to participate in our SASS-able activities.
* Indicates required question
Email
*
Your email
NDIS Participant
NDIS Number
*
Your answer
Request Date
MM
/
DD
/
YYYY
Preferred Title
*
Mr
Miss
Master
Ms
Mrs
Other:
First Name
*
Your answer
Surname
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mobile
*
Your answer
Email
*
Your answer
Address
*
Your answer
Disability Information
Disability Information
*
Psychosocial
Intellectual
Mental Health
Autism
Down Syndrome
Physical
Other:
Preferred Worker
*
Male
Female
Prefer not to say
Other:
Indigenous Status
*
Aboriginal
Torres Strait Islander
Both
Neither
Interpreter Required
*
Yes
No
Preferred Language
*
Your answer
Cultural Considerations
*
Your answer
Participant's Nominee Contact (Next of Kin)
Name
*
Your answer
Relationship to Participant
*
Your answer
Address
*
Your answer
Mobile
*
Your answer
Email
*
Your answer
Alternative Contact
*
Your answer
NDIS Plan
Start Date
*
MM
/
DD
/
YYYY
End Date
*
MM
/
DD
/
YYYY
Billing Details (please note that we can only provide services to plan and self managed participants).
*
NDIA
Third Party
Self Managed
Plan Manager Email
*
Your answer
Who is Completing this Request?
Agency Name
*
Your answer
Contact Person
*
Your answer
Email
*
Your answer
Mobile
*
Your answer
About the Services
Days Required (All sessions run between 9.00am and 5.00pm
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
Please specify the preferred duration of sessions (please note a minimum of 3 hour sessions applies).
*
Your answer
Activity Preference
*
Animal Husbandry and Petting
Gardening
Bushwalking
Sports and Games
Arts and Craft
Camp Oven Cooking
Interactive Circus Performance
Woodworking
Archery
DJ Lessons
Guitar and Drum Lessons
Cooking Classes
Mindfulness Program (Yoga and meditation)
Other:
Dietary Requirements
*
Vegetarian
Vegan
Kosher
Halal
Gluten-free
None
Other:
Allergies
Your answer
Other important information
Your answer
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