Make a Referral for Disability Support

Refer to Lifely's NDIS & Disability Services: A young woman with Down syndrome smiles while filling out a referral form on her phone, showing independence and ease of access to disability and NDIS services.
Refer to Lifely's NDIS & Disability Services: A young woman with Down syndrome smiles while filling out a referral form on her phone, showing independence and ease of access to disability and NDIS services.

Refer Yourself or Someone Else to Lifely’s Disability and NDIS Services

Need support or know someone who does? Use this form to refer yourself or someone else for Lifely’s NDIS and disability services in Ballarat, Bendigo, Mildura, and surrounding regions. Whether it’s help navigating the NDIS, accessing disability services, or finding the right support for daily life, we’re here to assist.

Referring is quick and easy—fill out the form below, and our team will be in touch to discuss the best support options.

Who Can Use This Referral Form?

  • Refer yourself if you need disability support.
  • Family, carers, and nominees can refer someone they support with their NDIS plan.
  • Support coordinators, NDIS planners, and professionals can refer people to Lifely’s services.

Need more information before you refer someone for NDIS supports or other disability services? Contact us at 1300 799 421 or email intake@lifely.org.au, and we’ll be happy to assist!

Disability and NDIS Support Referral Form

Use this form to connect yourself, a family member, or someone you support with Lifely’s NDIS and non-NDIS disability services.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

    NDIS Participant Information

    Write your details as they appear on your NDIS plan. If you're filling out the form for someone else, please write their details.
    Name*
    Please enter a number from 0 to 100.
    Address*

      Primary Contact Information

      Please provide your name, phone number, and email address. If you're filling out the form for someone else, include the primary contact person's details.
      Name*
      What is your relationship to the NDIS participant?*

        NDIS Information

        Enter your NDIS details, including your NDIS number and plan start and end dates. If you have a copy of your plan or goals, you may attach it. If you're filling out the form for someone else, please write their details.
        Your NDIS number a unique number given to each person who joins the National Disability Insurance Scheme. It helps identify their NDIS plan and access support services.
        NDIS Plan Start Date
        NDIS Plan End Date
        Max. file size: 50 MB.

          Disabilities and Health Conditions

          Provide details about your disabilities, health conditions, and support needs to help us understand how to best assist you. If you're filling out the form for someone else, please write their details.
          A primary disability is the main disability or condition that has the most impact on your daily life and is the main reason you receive NDIS support.
          Tell us about any other disabilities, health conditions, or support needs so we can better assist you. If you're filling out the form for someone else, please list their details.
          Drop files here or
          Max. file size: 50 MB.
            Please upload any relevant Health Support Plans (e.g., Epilepsy Management Plan, Asthma Management Plan, or other medical support plans) that outline important medical needs, daily management strategies, and emergency responses.

              Behaviours of Concern

              Provide information about any behaviours of concern. A behaviour of concern is an action that might hurt you or others or make it harder for you to take part in daily activities. It often means you need extra support. If you're filling out the form for someone else, please list their details.
              Do you have behaviours of concern?*
              Tell us about any behaviours of concern and how they impact your life and support needs, so we can better assist you. If you're filling out the form for someone else, please list their details.
              Do you have a Behaviour Support Practitioner?
              A Behaviour Support Practitioner is a professional trained in positive behaviour support who works with you and your support network to manage concerning behaviours develop the BSP and improve your quality of life.
              Behaviour Support Practitioner Name
              Max. file size: 50 MB.
              Please attach the latest Behaviour Support Plan (BSP), which explains how to support the person’s needs and manage behaviours of concern.

                Support Needs and Schedule

                Describe the type of disability support services you need. We will do our best to accommodate your needs but may need to discuss availability further. If you're filling out the form for someone else, please list their needs and preferences.
                Please select the services you need*
                Please select the services you need. If you're unsure, choose the options that best match your situation. If you're completing this form on behalf of someone else, please outline their support needs and preferences.
                Monday
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                Saturday
                Sunday
                Use this section to share any other important details that may help Lifely provide the best support. This could include specific needs, preferences, communication methods, cultural considerations, or any other relevant information not covered in the form.

                  Consents

                  Consent for contact*
                  Consent*
                  Subscribe
                  Consent

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                Why do you need so much information about my health?

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