Full name
Date Of Birth
Gender MaleFemaleOther
Pronouns
Phone
Email
NDIS number
Company
Suburb
Postcode
Address
Type of address Own/private homeRental propertySupported accommodationAged care facilityOther
Request Details
When do you need these supports? As soon as possibleWithin the next monthWithin the next 2 monthsNot sure, Just investigating
How is your NDIS plan managed? Agency ManagedPlan ManagedSelf‑ManagedNot specified
Participant diagnoses / Relevant medical history
Allergies / medical action plans
Client goals
Plan Dates From to
How is your NDIS plan managed? Agency ManagedPlan ManagedSelf‑Managed
Plan manager name
Plan manager phone
Plan manager email
Who will sign the documents? ParticipantNominee / POA / Child representative
Name
Relationship
Who should we contact regarding support shifts? ParticipantAbove mentioned Nominee / POA / Child representativeOther
Cultural background Aboriginal and/or Torres Strait IslanderCulturally and linguistically diverseOther
Other Cultural background
Are there any cultural or religious practices or requirements our team should be aware of? NoYes
Other cultural or religious
Do you have any preferences for your support worker? NoYes
Request Details:
Do you know when do you need support? NoYes
Day(s) of the week MondayTuesdayWednesdayThursdayFridaySaturdaySunday
How often? Every weekOne‑offEvery 2 weeksEvery monthOther
Start Date
Start Time
End Time
Primary language spoken
Current mobility status WalkingWalking with aidWheelchairHoist transfers
What are the primary modes of communication? (please select all that apply) Speech in sentencesSpeech in single wordsVocalisationsFacial expressionsBody languageGesturesKey Word SignCommunication aidsOther modes of communication
Are there sensory needs we should consider to provide comfortable and inclusive support? NoYes
Does the person experience behaviours requiring consideration or management? NoYes
Does the person access a positive behaviour support service? NoYes
Is there a Behaviour Support Plan in place? NoYes
Does the person, or anyone we might see with them, have a history of aggression or violence? NoYes
Are there any active court orders pertaining to this client? NoYes
Potential issues for staff visiting? NonePetsHoardingAlcohol / drug useFirearmsOther
Anything else we should know?
Upload supporting documents
Relationship to participant AlliedFamily MemberFor MyselfFriendGeneral Practitioner/Medical SpecialistLegal RepresentativeNDIS Planner/LACNDIS Support CoordinatorOther
Your First Name
Your Last Name
How did you find us? A Doctor or Therapist or Service ProviderEnable Life WebsiteFacebookGoogle searchAn NDIS LACService ProviderA Friend or Family MemberSupport CoordinatorWord of MouthOther
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