10-Week Group Based Activity for Adults Referral Form PARTICIPANT INFORMATION First Name Last Name NDIS Number Participant Date of Birth Gender Male Female Transgender Non-Binary Genderfluid Agender Prefer not to state Other Phone (Parent / Plan Nominee / Legal Guardian) (###) ### #### Email (Parent / Plan Nominee / Legal Guardian) * Address Address 1 Address 2 City State/Province Zip/Postal Code Country GUARDIAN/PLAN NOMINEE INFORMATION Only complete if applicable First Name Last Name Relationship to Participant: Phone Email (required) NDIS PLAN DETAILS NDIS Plan Details NDIS Managed Plan Managed Self-Managed NDIS Plan Start Date MM DD YYYY NDIS Plan End Date MM DD YYYY Plan Management Provider Name (if applicable) Plan Management Provider Phone Number (###) ### #### Plan Management Provider Email Address SUPPORT COORDINATOR DETAILS (if applicable) Support Coordination Provider Name Support Coordinator Name Support Coordinator Phone Number (###) ### #### Support Coordinator Email Address GROUP BASED ACTIVITIES INFORMATION: Artistic Exploration Week 1: Friday 10th October 2025 Clay Magnet Making & Painting Week 2: Friday 17th October 2025 Mosaic Clocks Week 3: Friday 24th October 2025 Canvas Painting Week 4: Friday 31st October 2025 Frame Decorating & Jewellery Week 5: Friday 7th November 2025 Flower Mobile Making Week 6: Friday 14th November 2025 Resin Art Work Week 7: Friday 21st November 2025 Bird House Painting Week 8: Friday 28th November 2025 Punch Needling Coasters Week 9: Friday 5th December 2025 Christmas Wreath Making Week 10: Friday 12th December 2025 Gift Making - Soaps & Tags ADDITIONAL REFERRAL INFORMATION (optional) Please include any additional information you feel will be applicable REFERRER DETAILS Referral Form Completed by: You have successfully submitted your referral for Inclusive Disability Assist’s ‘Group Based Activities for Children - School Holiday Program’. A member of our dedicated team will be in contact with you, to discuss your referral. Should you have any immediate queries regarding your referral, please don’t hesitate in contacting our office on (07) 3448 6365 or emailing us at ‘ndis@inclusiveassist.org’.
