SOCIAL SUPPORTS REFFERAL PROGRAM DOCUMENT: HOOPS 4 HEALTH (H4H) STRATEGIC PARTNERSHIP

1. PARTICIPANT IDENTIFICATION

First name

Last name

Participant Background (Physical capabilities, legal issues and specific needs)

Birthday

Month

Day

Year

Gender

Male

Female

Other

2. STAKEHOLDER & REFERRER DETAILS

Organisation and Brief history:

Organisational Contact Person:

Email

Phone

3. CLINICAL RISK & SAFETY ASSESSMENT

Mandatory Disclosure for Duty of Care and Program Integrity.

Medical Conditions/Physical Health: (e.g., Asthma, Epilepsy, Cardiac)

Allergies/Anaphylaxis:

Mobility/Gross Motor Support Needs

Behavioural Triggers/Risk to Self or Others:

Safety/Legal Orders: (e.g., IVO/AVO, Kinship Avoidance Protocols) __________________________________________________________________

4. CULTURAL & GENDER PROTOCOLS

Requested Stream:

Men's

Women's

Youth(Under 25)

Inclusion Status: H4H is Aboriginal-led and inclusive of all backgrounds. List specific requirements for cross-cultural engagement:

5. NDIS ALIGNMENT & SERVICE STRUCTURE

Fee Model:

Individual Placement

Collective Agency Cohort

Primary NDIS Goal Category:

Capacity Building – Social & Community Participation

Improved Daily Living

Hoops4Health

Hoops4Health Inspiring healthier, stronger communities through basketball and holistic well-being.

Contact Info:

3/43 Marjorie Street, Pinelands,NT, 0820

PO Box, 114 Berrimah, NT, 0828

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