Participant Pre-Screening Form

Estimated completion time: 10–15 minutes · 8 sections · All information is kept strictly confidential

Referrer Details 1 of 8

About You

We start by collecting your details — the person making this referral. This helps us follow up with the right person and keeps the process running smoothly. Whether you're a family member, a support worker, a GP, or the participant themselves, we just need to know who you are and how to reach you.

Your full name

Organisation or agency

Your relationship to the participant

Your phone number

Your email address

Section 01

About the Participant

Now tell us about the person you'd like Xyston to support. Don't worry if you don't have every piece of information — fill in what you can. The more detail you're able to share, the better we can prepare to provide the right support from day one.

First name

Last name

Date of birth

NDIS number

9-digit number on their NDIS plan

Participant's phone number

Participant's email address

Home address

Suburb

State

Postcode

Living situation

Primary contact person

If someone other than the participant — such as a parent, guardian, or carer — is the best first point of contact, please add their details here.

Contact's full name

Contact's phone number

Their relationship to the participant

Section 02

NDIS Plan & Goals

This section is about the participant's NDIS plan — the document that outlines their funded supports and budget. It also covers what the participant hopes to achieve. If you have a copy of the plan handy, great — if not, fill in what you know and our team can help clarify the rest during our initial conversation.

Plan start date

Plan end date

Plan management type

Support Coordination level

Support Coordination budget (approximate)

Funded support areas

Participant's goals

Participant's strengths and resources

Section 03

Support Needs

This section helps us understand the participant's disability and their current situation. We want to know what supports are already in place and what gaps exist. The more context you can share, the better we can prepare — whether that means coordinating a smooth handover from another provider or starting fresh with the right approach from the beginning.

Primary disability or condition

Additional details about the disability

Current supports

Tell us what support the participant is already receiving. This helps us avoid duplication, identify gaps, and plan a smooth start to our coordination.

Current Support Coordinator (if any)

Other supports currently in place

Handover notes (if transitioning from another provider)

Barriers and health considerations

This section helps us understand what's getting in the way of the participant achieving their goals, and any health factors we should be aware of for everyone's safety.

Barriers to achieving goals

Funding or service gaps

Medical alerts and health considerations

Section 04

Risk Considerations

This section helps us prepare for safe and appropriate service delivery. Being upfront about risk doesn't mean the participant can't be supported — quite the opposite. The more we know, the better we can prepare our team and put the right safeguards in place before we begin. All information is handled with strict confidentiality in accordance with the NDIS Code of Conduct and our Privacy Policy.

Known risks or safety concerns

Does the participant have behaviours of concern?

Yes No

Are restrictive practices currently in place?

Yes No

Is there an existing Safety or Behaviour Support Plan?

Yes No

If yes, please upload a copy in Section 07 — Documents.

Overall complexity level

Section 05

Legal & Consent

This section covers the legal side of the referral. We need to know if anyone holds formal legal authority to make decisions on behalf of the participant, and we need your consent to contact the participant and share information with other providers as part of coordinating their supports. This is standard practice under the NDIS and is required for us to act in the participant's best interests.

Decision Maker / Guardian / Power of Attorney

If no formal guardianship or power of attorney applies, leave this section blank.

Full name of decision maker

Their role or authority type

Is there a formal Guardianship or SAT/VCAT Order?

Yes No

Conflict of Interest

Under the NDIS Code of Conduct, any potential conflict of interest must be disclosed. If unsure whether this applies, it's better to declare and discuss it.

Do you wish to declare a potential conflict of interest?

Yes — I'd like to declare a conflict No conflict to declare

Consent Declarations

To proceed with this referral, we need your consent to the following. These allow us to act on the participant's behalf in coordinating their services. All three are required before we can formally accept the referral.

Section 06

Communication & Culture

Great support coordination depends on great communication. This section helps us understand how the participant prefers to communicate, whether any adaptations are needed, and if there are any cultural or spiritual values we should be mindful of. Person-centred care means meeting people where they are — on their terms.

Preferred contact method

Best time to make contact

Does the participant require an interpreter?

Yes No

Cultural, religious, or spiritual considerations

Communication needs or preferences

Anything else we should know?

Section 07

Documents & Declaration

Almost done! Upload any supporting documents and then sign the declaration at the bottom. Documents are helpful but not all are essential right now — if you can't upload something today, our team can follow up to collect it. We just need your signed declaration to submit the referral.

Supporting Documents

Accepted formats: PDF, DOCX, JPG, PNG — max 10 MB per file. Upload what you have — we can collect anything missing during our follow-up conversation.

NDIS Plan or Plan Summary

Current plan document or most recent plan summary

Budget Statement

Showing Support Coordination funding and remaining balance

Medical or Allied Health Reports

Diagnosis, assessment, or specialist letters (optional but helpful)

Safety or Behaviour Support Plan

If applicable — indicated in Section 04

Guardianship or Legal Orders

If applicable — indicated in Section 05

Declaration

I declare that the information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that submitting this form does not guarantee acceptance into Xyston's services. I consent to Xyston contacting me and the participant to discuss this referral.

All information provided will be managed in accordance with Xyston's Privacy Policy and the Privacy Act 1988 (Cth).

Date

Your signature

Sign using your mouse, stylus, or finger

Participant Pre-Screening Form

About You

About the Participant

Primary contact person

NDIS Plan & Goals

Support Needs

Current supports

Barriers and health considerations

Risk Considerations

Legal & Consent

Decision Maker / Guardian / Power of Attorney

Conflict of Interest

Consent Declarations

Communication & Culture

Documents & Declaration

Supporting Documents

Declaration

Referral Submitted