NEW CLIENT ENQUIRY FORM
New Client Enquiry Form
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Please complete the form below if you would like to enquire about our services and programs!
Representative's Full Name
Email Address
Phone Number
Participant's Full Name
Participant's Date of Birth
The suburb the participant's is based in:
Does the participant have a current NDIS plan?
Yes
No
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What are the participants disabilities?
Does the participant have any of the following high support needs?
Epilepsy
Behavioural Concerns
Restrictive Practices
Complex Bowel Care
Enteral Feeding
Tracheostomy Care
Urinary Catheters
Ventilation
Subcutaneous Injection
Manage Diabetes
Severe Dysphagia
Swallowing Difficulties
Is there an Epilepsy or Seizure Management Plan in place?
Is there a Behavioural Management Plan in place?
Is there a Restrictive Practices Plan in place?
Does the participant need medication administered to them by a support worker during support sessions?
Yes
No
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Which services and programs are you interested in?
Individual Support
Group Programs (Children)
Group Programs (Teenagers)
Group Programs (Adults)
Support Coordination
Other
Following on from the previous question, please provide more information (the days and hours needed, 1:1 or 1:2 ratio, male or female worker needed etc)
Please advise the date you need support/services to start (please put today's date if you need support/services to start ASAP)
Please advise how your funding is managed:
Self Managed
Plan Managed
Agency Managed
If your funding is Plan Managed, please advise your Plan Manager details (contact name, organisation name, phone number, email address):
Is there any other information you would like to provide?
How did you find out about us?
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