Your Journey to Independent, Dignified Living Begins Here

Get Started with NDIS Support

Whether you are a new NDIS participant exploring your options or a support coordinator referring someone in need, Break Barriers is ready to walk alongside you. Our person-centred approach means every support plan is built around your goals, your needs, and your life.

HOW IT WORKS

How to Get Started - 3 Simple Steps

01 Submit Your Form

02 We Get in Touch

03 Your Support Begins

CLIENT REFERRAL FORM

Refer a Client to Break Barriers

Are you a support coordinator, healthcare professional, or family member referring someone for NDIS disability support? Use the form below to submit a client referral. Our intake team will follow up promptly to begin the onboarding process.

PARTICIPANT INTAKE FORM

New Participant? Start Here.

If you are an NDIS participant who is new to Break Barriers, this Participant Intake Form is your first step. Completing this form helps us understand your goals, your current support needs, and how we can build the right plan around your life. There are no wrong answers — just honest ones.

Client Referral Form

Participant Intake Form

Client Details

Name

Date of Birth

Gender

Stage of Development

Contact Details

Home Phone

Mobile Phone

Work Phone

Email Address

Cultural Background

Country of Birth

Preferred Language

Interpreter Required?

PLAN Details

Plan Type

NDIS Number

Plan Start Date

Guardians Details (if applicable )

Name

Date of Birth

Home Phone

Mobile Phone

Work Phone

Email Address

Address

Risk Factors / Alerts

Potential Risks

Medical History

Presenting challenges / Problems

Other Relevant Current and Historical Information

Presenting Disabilities

Participants’ Culture, Diversity, Values and Beliefs, including sexual expression needs

Participants’ Preferences (e.g., worker preference, needs and wants.)

Behaviours in Need of Support / Intervention

Priority	Target Behaviours	Warning Signs/Triggers
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7.

Preventative Strategies and Interventions

Priority	Preventative Strategies and Interventions Implemented
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5.
6.
7.

At-Home Strategies and Interventions

Priority	Strategies	Beginning Date	Finish Date	Who Is Responsible For Implementation	Signed
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4.
5.
6.
7.

Outside-of-Home Strategies and Interventions

Priority	Strategies	Beginning Date	Finish Date	Who Is Responsible For Implementation	Signed
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2.
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5.
6.
7.

Second Home Strategies and Interventions

Priority	Strategies	Beginning Date	Finish Date	Who Is Responsible For Implementation	Signed
1.
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6.
7.

Online, Social Media, Gaming and Films

Priority	Strategies	Beginning Date	Finish Date	Who Is Responsible For Implementation	Signed
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7.

Crisis Plan 1

Priority	Behaviour	Actions	Who Has The Responsibility
1.
2.
3.

Crisis Plan 2

Priority	Behaviour	Actions	Who Has The Responsibility
1.
2.
3.

Crisis Plan 3

Priority	Behaviour	Actions	Who Has The Responsibility
1.
2.
3.

Crisis Plan 4

Priority	Behaviour	Actions	Who Has The Responsibility
1.
2.
3.

Participants Preferred Staff & Worker

Person 1 - Name and Position

Person 2 - Name and Position

Person 3 - Name and Position

Person 4 - Name and Position

Review

Review Date

Who is Involved

How is it Monitored

Client / Guardian Declaration

I consent to my information being provided to for the purposes of referral, service delivery and inclusion in de-identified data reporting.

Full Name

Date

Signature of Client/Guardian