Respite Referral form

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About Us

We provides disability and mental health support services to empower individuals to live life on their own terms. We have over 30 years of experience in disability support and advocacy, with a toolbox of skills to help NDIS participants achieve their goals and a framework to measure impact.

Contact

Contact Info

D214 Canberra Technology Park 49 Phillip Avenue WATSON ACT 2602
0421 794 901
0251 047 780
info@abilityseer.com.au
Week Days: 09.00 to 18.00 Sunday: Closed

NDIS Short-Term Accommodation/Respite Referral Form

First Name *

Last Name *

Gender

Male

Female

Indeterminate/Intersex/Unspecified

Participant Address *

Participant Contact Number *

Participant Email *

Alternative Contact * If the participant is under Guardianship please provide their details here as well.

Relationship to Participant *

Participant Alternative Contact Number/Email *

Please list of the diagnosis of the Participant *

Breif Description about the Participant, their diagnosis and support needs *

Participant NDIS Goals

NDIS Goal 1 *

Description of Need *

How STA Supports Goal? *

NDIS Goal 2 * Please write NA in additional goal's options if there is no more than one NDIS goal.

Description of Need *

How STA Supports Goal? *

NDIS Goal 3 * Please write NA in additional goal's options if there is no more than one NDIS goal.

Description of Need *

How STA Supports Goal? *

NDIS Goal 4 * Please write NA in additional goal's options if there is no more than one NDIS goal.

Description of Need *

How STA Supports Goal? *

NDIS Short-Term Accommodation/Respite Eligibility Guidelines

Short-Term Accommodation, including respite, is funding for support and accommodation for a short time away from your usual home. It covers the cost of our care in another place up to 14 days at a time. You might have a short stay with other people, or by yourself. It's often funded when your usual carers aren't available, or for you to try new things.

NDIS Short-Term Accommodation and Respite Eligibility Acknowledgement *

I have read and understood the NDIS STA/Respite eligibility guidelines displayed above

I can confirm that myself or my NDIS client is eligible for STA/Respite through their NDIS Plan

I can confirm that my eligibility to access NDIS Short Term Accommodation/Respite is mentioned in my plan or I can submit the eligibility confirmation given to me by a NDIA representative if required

Do you consider STA/Respite value for money? *

Yes

Behaviour Support Plan and Restrictive Practicies

Do you have a behaviour support plan in place? *

Yes

Please upload a copy of the Behaviour Support Plan here.

Choose a file

No file chosen.

Are there any restrictive practices in place for the participant? *

Yes

AbilitySeer is not registered to implement restrictive practices.

If you do not have a Behaviour Support Plan please mention all the details regarding participant's behavioural challenges. *

NDIS Participant Number *

NDIS Plan Date *

SunMonTueWedThuFriSat

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NDIS End Date *

SunMonTueWedThuFriSat

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How is the participants NDIS plan managed? *

Self Managed

NDIA/Agency Managed

Plan Managed

Plan Manager's Name * If you are Self-Managed or NDIA Managed, Please write plan management type here.

Plan Manager's Contact Number

Email Invoices To *

Referrer Information

Referrers Name *

Role *

Referrers Contact Number *

Email *

NDIS Short Term Accommodation/Respite Pricing

Day	1:1 Rate/Day	1:2 Rate/Day	1:3 Rate/Day
Monday to Friday	$2098.8	$1049.40	$699.6
Saturday	$2682.32	$1341.16	$894.10
Sunday	$3396.56	$1698.28	$1132.18
Public Holiday	$4110.8	$2055.40	$1370.26

Prices are according to NDIS Pricing Arrangement and Limits 2024-2025.

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Building the capability of people with disability and community sector orgs. We specialise in up skilling dynamic community sector employees, equipping them with skills that ensure they survive and thrive in a post-NDIS landscape.

Acknowledgement

In the spirit of reconciliation AbilitySeer acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

AbilitySeer supports the rights of the child by protecting children from harm and neglect, and by upholding the principles of the United Nations Convention on the Rights of the Child

About Us

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