Referrals

We firmly believe in the power of community and the value of personal connections. Our referrals program is an essential part of our mission to spread the magic of UnleashedX to as many individuals as possible, ensuring that everyone has the chance to experience life to the fullest.

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Client Name *

Client Email

Client Address *

Client Gender

Male
Female
Other

Client Goals

Vehicle requirements (would the care worker need one?)

Yes
No
Maybe

Anything Else to Add?

Please list days, times and number of hours you require support:

Mobility Support Required?

Yes
No
Maybe

Personal Care Required?

Yes
No
Maybe

Medication Support Needs?

Yes
No
Maybe

Client Diagnosis

Referrer Name

Phone Number

Email *

Address

Services Required *

Short Term Accommodation (STA)
Accommodation-Only Option at Lake Macquarie Manor
Assistive Technology Support

Select Additional Interest *

Jet boating
Pontoon boat
4wding
Drones
Spa
Kayaking
3D printing
Fine dining
Virtual reality
Home brewing
Relax & chill
Other

Special Request or Other Information

What's the duration your referral is considering for their stay at UnleashedX? *

1-2 days
3-4 days
4-5 days
6+ days
Unsure

Is the individual you're referring eligible for NDIS funding to cover the expenses of their respite experience at UnleashedX? *

How will the funding for your UnleashedX referral be handled? *

NDIS Plan managed
NDIS Self managed
Other

Participant Consent *

I Agree

By Checking, I agree this participant has provided their verbal or written consent for this referral

We empower participants to build their capacity and skills, whether in social, environmental, cultural, or economic aspects, all while fostering community causes close to our hearts.

Contact Information

Phone: 0448 615 191
Email: spark@unleashedx.com.au
Location: Lake Macquarie, NSW.

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