NDIS New Referral Form – Counselling/Psychotherapy

    A Life Simply Lived Psychology - NDIS Client Required Information - Counselling

    It is a requirement that this information is filled out prior to therapy commencement. Our clinicians must be aware of this information to ensure they are best matching the therapeutic goals with what the client needs, and also to keep the administration process running smoothly.

    Plan Nominee Details (if not/ different to participant)

    NDIS Contact

    Support Coordinator Details (if applicable)

    Plan Management



    Disabilities (if unsure, please contact NDIS Support Coordinator)


    Allocated Funding
    Improved Daily Living Funds. Psychology – Assessment,
    Recommendation, Therapy and/or Training
    Item Reference Number
    Item Cost (hourly)

    (please select if it is known that participant will have an unplanned review)