STA Referral

Short Term Accommodation (STA) Referral Form

Please complete all sections. Incomplete referrals will not be accepted. We’ll get back to you as soon as possible.

- Step 1 of 2

Date referred *

Today’s date

Service to be delivered by

STA Location

Meek Street
Other

Please specify

Is this person currently accessing other AEG services? *

Participant name *

NDIS number *

Date of birth *

Address *

Participant contact phone *

Participants email *

Is the participant a trusted informant regarding their needs and risks? *

If No, please provide details *

Suitability to reside with other participants? *

Do they require 1:1 support or other? *

Plan start date *

Plan end date *

Billing details *

Plan management
Self-management
NDIA managed

Business name *

Plan manager details

Contact details *

Plan manager details

Invoicing email *

Plan manager details

Please attach any relevant assessment reports, if available

NDIS Coordinator Details

Name *

Contact number *

Email address *

Background Information

Primary Diagnosis *

Secondary Diagnosis (or Suspected Secondary)

Brief snapshot into participants relevant needs *

Major Risks/Concerns, either to participant or us during their stay *

Any other considerations for participant or staff *

Booking Preferences

Please answer these questions with the assistance of the participant you are referring. Our aim is to tailor their stay to make them as comfortable and engaged as possible. All preferences will be confirmed when we contact them to discuss the dates of their booking.

Ratio of support *