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Step
1
of 5
Let’s get started
I am a Participant
I am a Referrer or Nominated Representative
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My Details
Your role
*
Parent
Support Person
LAC/Support Coordinator
Plan Manager
Other
First Name
*
Last Name
*
Phone
Email
*
Postcode
*
Participant Details
First Name
*
Last Name
*
Preferred Name
Preferred Pronoun
Date of birth
*
Enter Suburb
*
State
*
Note: State will be auto generated based on your Suburb
Postcode
*
Note: Postcode will be auto generated based on your Suburb
Reason for Referral
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Next
How would you/participant prefer to receive our services?
*
Telehealth
Face-to-face
Either
Which services are you/participant interested in?
Help With Everyday Living
Help With Development
Help with mobility
Assistive Technology, Equipment and Aids
Home Modification Occupational Therapy
Driving Service
Which services are you/participant interested in?
Occupational Therapy
Psychology
Physiotherapy
Positive Behaviour Support
Exercise Physiology
School Leave Employment Support
Speech Pathology
Employment-related Assessment and Counselling
I am unsure
Key Worker
Previous
Next
Do you have an approved NDIS plan or are you awaiting approval?
I have an approved plan
I am awaiting approval
NDIS Participant Number
*
Plan Start Date
*
Plan End Date
*
How will funds be claimed?
*
Agency Managed
Plan Managed
Self-Managed
Attach documents
Click or drag a file to this area to upload.
Next
Tell us more about the participant
Name
*
Gender
Male
Female
Agender
Gender Diverse
Other
Email
*
Phone
*
Address
Primary disability
Other relevant health information
Participant State Do
Is there a Guardian involved?
Yes
No
Is there a Support Coordinator involved?
Yes
No
Who is the Plan Nominee or Child Representative?
Me
Other
Will an interpreter be needed?
Yes
No
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