Make a Referral – Leah Bett Nursing Services

Leah Bett Nursing Services

(08) 8912 0650
admin@lbns.com.au
Mon - Fri : 8.30 am – 5.00 pm

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Make A Referral

Make a Referral

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Make a Referral

Please fill-in the referral form below.

Referrals must be made with the participant’s consent, including their nominee or legal guardian.

Alternatively, download the Referral Form, fill it in and email it to: admin@leahbettnursingservices.com.au

Download the Form

Referral Form

Where did you hear about Leah Bett Nursing Services?

Title

Mr Mrs Ms Miss Other

First Name

Surname

Date Of Birth

Gender

Male Female Other

NDIS No

Residential Address

Telephone Number

Email Address

Identifies as

Aboriginal Aboriginal and Torres Strait Islander Torres Strait Islander Neither

Plan Start Date

Plan End Date

Self-Managed Plan Managed NDIS Manage

If Plan Managed, please provide the details of the plan manager:

Company Name

Contact Person Name

Telephone Number

Email

Emergency contact / next of kin (if available)

Name

Phone Number

Email

Relationship

Address

Is the person requiring support…

Please Specify If Others

How many hours are required for the requested services?

Hours per week

Supports required

CURRENT SUPPORTS – please specify below any current/ongoing support and/or support staff who can assist in providing relevant history of day-to-day activities?

What specific support is required?

Please briefly describe the participant’s status (if bed restricted, wheelchair etc.)

Please tick all that apply

Intellectual disability Physical disability Neurological disability Psychosocial/mental health disability Medical conditions on board

Please provide any additional information regarding the clinical nursing support needed

Name of person making this referral

Company Name (if applicable)

Contact Person Name

Phone Number

Email

Date of referral:

Name

By checking this box, I agree to share my form responses.

By checking this box, I agree to share my form responses.

Leah Bett Nursing Services recognises all Aboriginal and Torres Strait Islander people as the first Australians and Traditional Custodians of Australia.

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(08) 8912 0650
0422 566 009
admin@lbns.com.au
4 – 5/70 Todd Street, Alice Springs NT 0870, Australia

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Full Name

Date Of Birth

Address

How long have you lived at this address?

Home Telephone number

Mobile Telephone number:

Email address

Driver’s Licence (state)

Driver’s Licence (Number)

Do you have your own transport to and from work?

Yes No

Do you have previous experience working in Disability?

Yes No

If YES – Please outline below

Please provide details of previous or present employment below:

Name of Company:

Position held:

Dates of Employment:

To

Reason for leaving:

Please list any licences, certifications, or accreditations that you hold (First Aid Certificate).

Do you have, or have you ever had, any disability, injury or illness which may affect your ability to work freely in this position?

Yes No

If YES, please provide details:

Have you ever been convicted of a crime?

Yes No

If YES, please provide details:

Are you an Australian citizen or permanent resident?

Yes No

If NO, please provide proof of your authority to work in Australia:

Do you identify as being of Aboriginal or Torres Strait Islander descent?

Yes No

Please provide the details and contact information of reference providers:

Name

Telephone Number

Organisation

Position:

By checking this form, I authorise Leah Bett Nursing Services Pty Ltd to contact my reference providers to verify the information provided.

Dated