NDIS Referral Form | Kennix Care

Step 1 of 6

Service(s) Requested

Select Required Service(s) Required

Positive Behaviour Support (PBS) Disability Support Community Nursing Support Recovery Coaching Core Support Other

Core Support Category / Details Required

Client First Name Required

Client Last Name Required

Client Date of Birth Required

Client's NDIS Number Optional

Client Phone Number Optional

Client Email Address Optional

Client Street Address Optional

City / Suburb Required

State / Province Optional

List Client's Diagnosis Optional

Complete this section if the participant has a nominee, guardian, or primary emergency contact person.

Guardian First Name Optional

Guardian Last Name Optional

Guardian Phone Number Optional

Guardian Email Address Optional

Guardian Address Details Optional

Referrer First Name Required

Referrer Last Name Required

Referrer Organisation Optional

Referrer Phone Number Required

Referrer Email Address Required

Reason for Referral Required

If PBS, list behaviour of concern if known Optional

List Restrictive Practice if Applicable Optional

Additional Information Optional

Funding Amount for Service ($) Optional

Plan Management Type Optional

Plan Manager Organisation / Contact Optional

Is this PACE Funding? Optional

Yes No

List PACE Funding Details / Plan Reference Optional

Upload NDIS Plan / Supporting Documents Optional

File Limit Notice: Maximum size per file is 10 MB (Max total payload: 25 MB). Allowed: PDF, DOC, DOCX, JPG, PNG.

Drag & drop files here, or click to browse

Supported formats: PDF, DOC, DOCX, JPG, PNG • Max 10 MB per file

Need help with referral?

Our intake specialists are available to guide you or assist over the phone.

Direct Phone

0433 007 879

Intake Email

NDIS Registered Care

We adhere to strict NDIS Quality and Safeguards Commission standards across all WA statewide services.

Next Steps

What happens after you submit?

Here is our seamless 4-step intake process once we receive your form.

Form Received

Your step-by-step referral details are securely logged into our system.

24–48hr Review

Our intake team promptly reviews your funding and specific participant needs.

Intake Consultation

We reach out to discuss goals, match suitable practitioners, and issue a Service Agreement.

Support Commences

Compassionate, person-centred care begins without any unnecessary delays.

Make a Referral

Referral Submitted Successfully!

Service(s) Requested

Need help with referral?

NDIS Registered Care

What happens after you submit?

Form Received

24–48hr Review

Intake Consultation

Support Commences

File Upload Notice

Make a Referral

Referral Submitted Successfully!

Service(s) Requested

Need help with referral?

NDIS Registered Care

What happens after you submit?

Form Received

24–48hr Review

Intake Consultation

Support Commences