NDIS Referral Form – Optimum Intake Dietitians

Thank you for taking the time to complete this form. The details provided on this form will assist us to prepare a Service Agreement and allocate the most suitable dietitian.

To expedite the processing of your referral, kindly complete all relevant fields. This ensures prompt action on your referral.

    Plan Information

    Which section of the plan are you wishing to claim funds from?

    How do you manage the plan? (and how do you arrange payment for services)

    Have you added Optimum Intake as a My Provider in your NDIS plan (for plan or agency managed participants only)?

    Where would you like services provided? (Please note that where safety is a concern clinic visits are required).

    If Home visit: Is this accommodation a Group Home/SIL?

    Is this person fed via a PEG?

    Risk Assessment

    Safety Questions. Where a safety risk may be present, we may limit services to clinic-based services only.

    Is this participant in control of their behaviour at all times?

    Does this participant use recreational drugs in the home?

    Does this participant have a history of violence or aggression?

    Will a Support Worker or other representative be present during all visits?


    Full Support Co-ordinator name:

    Who provides consent for this Participant?

    Who shall we contact to book the appointment?

    Details of current plan

    Is there anything else you feel we should know before booking the first appointment?