New Client Enquiry Form
Please complete the form below if you would like to enquire about our services and programs!
Representative's Full Name
Participant's Full Name
Participant's Date of Birth
The suburb the participant is based in:
What is the participant's NDIS number?
Current NDIS Plan start date:
Current NDIS Plan end date:
What are the participant's disabilities?
Does the participant have any of the following high support needs?
Complex Bowel Care
Does the participant have Epilepsy? If Yes, is there an Epilepsy or Seizure Management Plan in place?
Does the participant have behavioural concerns? If Yes, is there a Behavioural Management Plan in place?
Does the participant require Restrictive Practices? If Yes, is there a Restrictive Practices Plan in place?
Does the participant need medication administered to them by a support worker during support sessions?
Which services and programs are you interested in?
Group Programs (Children)
Group Programs (Teenagers)
Group Programs (Adults)
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:
Plan Managed (please detail below)
If your funding is Plan Managed, please advise your Plan Manager details (contact name, organisation name, phone number, email address):
What other disability related services does the participant currently attend/access (physiotherapy, psychologist, speech therapist etc):
Is there any other information you would like to provide?
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