Welcome to Vital Ease!
Welcome to Vital Ease Referral page. Please complete the form below to submit a referral to our service. This information is not disclosed outside of our organisation without your permission.
Referral Date
Are you the: ClientOccupational TherapistCase ManagerOther
Referrer Given Name
Referrer Surname
Agency / Relationship
Days Worked
Referrer Phone Number
Referrer Email Address
Is the client aware of this referral and consents to the referral? YesNo
Given Name
Surname
Date of Birth
Phone Number
Email Address
GenderMaleFemaleNon-binaryPrefer not to answerNot stated
Street Address
Suburb
State
Postcode
Contact Given Name
Contact Surname
Relationship
Contact Phone Number
Contact Email
Ownership of homeClient OwnFamily ownRental PropertyPublic HousingSDAOther
Landlord/Strata Permission Please note that the referral will not be processed for quoting without a completed landlord approval.
Housing details
Please specify "other" accommodation type
HouseholdSingleCoupleFamilyOther
Property TypeHomeUnit/apartmentDuplexOther
Funding Agency Home Care Package (HCP)National Disability Insurance Scheme (NDIS)Department of Veterans Affairs (DVA)Short-term Restorative Care (STRC)Private Self-fund
Case Manager DetailsReferrerOther
Other Case ManagerEnter case manager details
NDIS Number
Home Modification FundingAgency ManagedPlan ManagedSelf-managedUnsure
Funding Available UnderCore supports - Low Cost ATCapital SupportsHome ModificationsUnsure
Please provide COS or LAC contact detailsPlease provide name, phone and email for the client's COS or LAC.
Modification TypeMinor Modifications (grab rails, ramps, step wedge, etc.)Major Modifications (major bathroom, ramps, steps with landing)Minor and Major Modifications
Builder Consult CompletedYesNo
List of required modifications
Please attach photos, drawings and/or specifications for each modification:
Further information regarding the client referral
