Full Name
Date of Birth
Current Address (Correctional Facility)
Anticipated Release Date
NDIS Number
Primary Disability / Diagnosis
Current Medical / Mental Health Conditions
Cultural Background / Language Needs
Prison Name
Prisoner ID / CRN (if applicable)
Contact Officer (Case Manager, Reintegration Officer, Parole Officer)
Role / Title
Phone Number
Email Address
Full Name
Organisation / Provider Name
Role (Correctional Case Worker, Support Coordinator, Parole Officer, Other)
Phone Number
Email Address
Plan Start Date
Plan End Date
Plan Management Type: ☐ NDIA-Managed ☐ Plan-Managed ☐ Self-Managed Plan Manager Contact Details (if applicable)
Upload NDIS Plan (optional file upload)
Living Situation Before Admission (e.g. home alone, with family, SIL, group home)
Informal Supports (family, carers, friends)
Services Currently Received (if any)
Previous Living Situation (before custody)
Anticipated Living Situation After Release (e.g. family home, private rental, transitional housing, Supported Independent Living)
Informal Supports (family, friends, community links)
Current Services / Supports Received (if any while in custody)
Required Services (tick boxes / multi-select): ☐ Personal Care (showering, grooming, meals) ☐ Community Nursing ☐ Mental Health Supports / Psychosocial Recovery Coaching ☐ Domestic Assistance (cleaning, shopping) ☐ Allied Health (OT, Physio, Psych, Speech, etc.) ☐ Transport / Community Access ☐ Behaviour Support ☐ Supported Independent Living (SIL) ☐ Short-Term Accommodation (respite) ☐ Other: __________ Preferred Start Date of Support
Preferred Days / Times of Support
Parole / Probation Conditions (if applicable)
Restrictions or Alerts (e.g. non-association, location restrictions)
Known Risks / Safety Concerns (optional, confidential section)
Emergency Contact (Name, Relationship, Phone)
GP / Primary Care Doctor (Name, Clinic, Phone)
Current Medications (optional)
Known Allergies (optional)
Signature of Referrer (Case Worker / Parole Officer)
Date
