1 Participant Details

Participant Name *

Date of Birth

Gender * Please select Male Female Non-binary / Other Prefer not to say

Landline

Mobile

Email

Residential Address

Language spoken at home

Do you need an interpreter? *

Yes No

Best way to contact you:

Phone call Email Post

Do you identify as Aboriginal or Torres Strait Islander?

Yes No

Is there a Guardianship or Administration order in place? *

Yes No

Family, Carer or Guardian Details: (Complete this section if someone else is managing support on your behalf)

Relationship to Participant:

Parent Guardian Carer Other

Full Name

Landline

Mobile

Email

2 Disability & Health Details

Please list any diagnoses, medical conditions, or health details we should know about *

3 Type of Support Needed

Tell us what kind of help you need and when. (For example: In-home help, support worker for social outings, Support Coordination. E.g., Monday, Wednesday & Friday, 9:00am – 3:00pm)

Support requirements *

4 Other Services You Currently Use

Any other providers, specialists, or support teams currently assisting you:

Provider / Service Name

Contact (Phone or Email)

How often do you see them?

Add another provider

5 Health Professional Contacts

Your GP, medical specialists, pharmacy, or clinics:

Name / Clinic

Phone Number

Address / Suburb

Add another health contact

6 NDIS & Funding Details

NDIS Number *

NDIS Plan Start & End Dates *

How is your NDIS funding managed? *

NDIA Managed Plan Managed Self Managed

Plan Manager or Invoicing Contact:

Contact Name / Plan Manager

Email for Invoices

Notes / Comments

7 Personal Preferences

1. Preferred Name

2. Cultural Preferences

3. Anything else we should know?

Declaration: To the best of my knowledge, all information entered in this form is accurate and complete.

Name of person completing this form *

Today's Date *

Relationship to participant *

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