Intake Referral

By sending this referral, you or your guardian/representative agree that the information you give can be shared with Facilitatrix. This information will be used to assess your needs, plan your support, and deliver services. Your personal information will be kept safe and used only for service and administration purposes, in line with privacy laws and Facilitatrix’s privacy and confidentiality policies. You can take back your consent at any time by contacting Facilitatrix.

By submitting this referral on behalf of another person, you confirm that you have their consent to provide this information, and  where relevant, that their guardian or decision-maker is aware of and agrees to this referral.

Please include name, role/organisation if appropriate and preferred contact details
Please include name and preferred contact details if different from above
NDIS Plan dates
Name, organisation and contact details
Family home, SIL, Hospital, no fixed address
Describe what is currently happening and how you would like Facilitatrix to support you
Gender preference, culture considerations, LGBTQIA+ safe and affirming supports, neuro-affirming practice, trauma informed practice, forensic/psychosocial experience
Preferred time of day, online/in-person preference, mobility access, visual supports, shorter sessions, quiet space
Epilepsy, ABI, dysphagia, pain, sleep, medication side effects, allergies, sensory needs, continence, nutrition

Acknowledgement of Country

The Facilitatrix Team is situated on Whadjuk Nyoongar Boodjar and works across the lands known as Western Australia. We have staff located across the lands known as Australia.

We acknowledge the Traditional Custodians throughout these lands, and pay our respects to their Elders, past and present. We recognise the Aboriginal and Torres Strait Islander communities’ strength and resilience in the face of colonisation and honour their continuing connection to land, water, and skies. We support the values that they have lived, for generations: inclusivity, sustainability, and regeneration.

Aboriginal FlagTorres Strait Flag

Acknowledgement of Lived Experience

We recognise and support the United Nations Convention on the Rights of Persons with Disabilities and are committed to upholding the convention and supporting carers, families, service providers and the community to do the same. We acknowledge and respect the unique experiences of those with a lived experience of disability.

Disability Flag

Acknowledgement of Diversity

We embrace diversity and support the elimination of all forms of discrimination, welcoming people irrespective of their age, faith, cultural background, gender identity, race, sexual orientation, physical or mental ability, neurodiversity, ethnicity, and perspective.

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