Lodge your referral

If your child is under nine years of age and you’re looking for access to NDIS Early Childhood support, please fill out the form below. If you already have an NDIS plan and have been allocated an EC Coordinator, please contact them directly.

Submit a referral for the NDIS Early Childhood Approach

1Consent

2Your Details

3Child Details

4Child’s Disability/Developmental Delay

5Education Supports

6Support Preferences

7Email copy

8Communication from Lifestart

Consent

By submitting this form, you consent to your details being shared with the NDIS.

Are you:(Required)

Parent or carer with parental responsibility of the child

Third-party referrer (eg; DJC, paediatrician, school, etc)

Has the parent or carer with parental responsibility of the child provided consent for this referral to be submitted?(Required)

Yes

You must attain consent before lodging a referral.

Name of person making the referral(Required)

Position title(Required)

Organisation/Agency(Required)

Phone

Referrer Email(Required)

Your Details

This field is hidden when viewing the form

Parent or Carer Details

Name(Required)

First Last

Have you been known by any other names?

Yes

Other names

Date of Birth(Required)

DD slash MM slash YYYY

Country of Birth(Required)

Parent/Carer's citizenship status(Required)

Australian citizen

Permanent resident

Visa holder

Visa's name and subclass

Gender(Required)

Female

Male

Non-binary

Prefer to self-describe

Prefer not to say

Gender

Would you like to provide preferred pronouns?

Yes

Preferred pronouns

Relationship to child(Required)

Mother

Father

Other

Phone(Required)

Email(Required)

Preferred contact method

Phone

Do you identify as Aboriginal or Torres Strait Islander origin?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Do you identity as Culturally or Linguistically Diverse? (CALD)(Required)

Yes

Does the family speak a language at home other than English?(Required)

Yes

Other language

Is an interpreter required for a phone conversation?(Required)

Yes

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Parental Responsibility

Does the child live with both parents?(Required)

Yes

Are there any current custody or court orders relating to the child?(Required)

Yes

Please provide details

Please upload any relevant court order documentation

Drop files here or

Max. file size: 256 MB.

Does the parent or carer hold parental responsibility of the child?(Required)

Yes

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Caseworker’s Details

Does the child live with others?

Yes

Please provide details

Caseworker Name(Required)

Name of Caseworker’s organisation(Required)

Caseworker’s Phone Contact

Caseworker Email(Required)

Location of Caseworker office (suburb/branch)

Child Details

Name(Required)

First Middle Last

What is the child’s preferred name?

Has the child been known by another name?

Yes

Child's other name

Date of Birth(Required)

DD slash MM slash YYYY

Child's Gender(Required)

Female

Male

Non-binary

Prefer to self-describe

Prefer not to say

Child's Gender

Does the child identify as Aboriginal or Torres Strait Islander?(Required)

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Is the child Culturally or Linguistically Diverse? (CALD)(Required)

Yes

Country of Birth(Required)

Citizenship status(Required)

Australian citizen

Permanent resident

Visa holder

Visa's name and subclass

Child's address(Required)

Address City/Suburb State/Territory Postcode Country

Does the parent/carer live at this address?(Required)

Yes

Parent/Carer's address

Does the child have any siblings with an NDIS Plan?(Required)

Yes

Please provide name and NDIS number

Child’s Disability/Developmental Delay

Does the child have a diagnosed disability?(Required)

Yes

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YES to disability

What disability has the child been diagnosed with?

Please provide as much information as possible. e.g. If Autism spectrum disorder record DSM- 5 Level if known or Cerebral palsy, GMFCS level if known.

Name and profession of person making the diagnosis of disability

e.g. Paediatrician, Clinical Psychologist, Neurologist

When was this diagnosed?

e.g. month/year

If you have any documents, such as a medical or report or diagnostic letter, please upload them here.

These will be required to support eligibility for some supports.

Drop files here or

Max. file size: 256 MB.

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Section Break

Is the child being supported by any therapists or health care workers, or are they currently under the care of a medical professional?

Yes

Please provide details

e.g. Paediatrician, GP or allied health professional), name of health professional and/or organisation name, how often is the support being provided.

Does the child have hearing loss?

Yes

Please upload medical or doctor’s report

Max. file size: 256 MB.

If your child participates in any community activities (for example, sport, religious or cultural activities), list them here

Education Supports

Is your child attending(Required)

Childcare/Preschool

Primary School

Neither

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Childcare/Preschool

What is the name of their childcare/preschool centre?(Required)

What days are they attending?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Does the child attends a second childcare/preschool centre?(Required)

Yes

What is the name of the second childcare/preschool centre?

What days are they attending?

Monday

Tuesday

Wednesday

Thursday

Friday

This field is hidden when viewing the form

Primary School

What is the name of their school?(Required)

Support Preferences

What kind of support are you open to receiving for your child?(Required)

Individual supports (where our Specialists work with you and your child one-on-one)

Group supports (where you attend workshops and support events where a Specialist works with a group of parents and children)

I’m open to a combination of both

What is your preferred way of for getting this support?(Required)

Face to face

Online

Flexible

Send a copy

Select below if you would like a copy of this referral emailed. Please check your spam folder if you have not received an email within 24 hours.

Email copy

to Parent/Carer

to Referrer

Communication from Lifestart

Lifestart offers a range of useful resources and workshops to help parents and carers to support their child’s development. Are you happy for us to email you with any other information or tips?(Required)

Yes

Are you happy to participate in surveys conducted by Lifestart or the NDIS?(Required)

Yes

Lodge your referral

Submit a referral for the NDIS Early Childhood Approach

Consent

You must attain consent before lodging a referral.

Your Details

Parent or Carer Details

Parental Responsibility

Caseworker’s Details

Child Details

Child’s Disability/Developmental Delay

YES to disability

Section Break

Education Supports

Childcare/Preschool

Primary School

Support Preferences

Send a copy

Communication from Lifestart

Therapy & Behaviour Support

Online Programs

Business, Organisational & Government Support

Ways to Give

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