Please enable JavaScript in your browser to complete this form.

Let’s get started

I am a Participant
I am a Referrer or Nominated Representative

Client Details

Layout

First Name *

Client Phone Number *

Date of Birth *

Last Name *

Client Email Address *

Street Address *

Layout

City *

State *

Postcode *

Client Representative Details (Parent/Guardian/Support Coordinator/LAC)

Layout

First Name

Last Name

Organisation Name

Layout

Phone Number

Street Address

Layout

City

State

Postcode

NDIS Details

Plan Management Option *

Plan Managed
Self Managed
Agency Managed

Layout

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

Layout

NDIS Number *

Available/Remaing Funding for Capacity Building Supports

Layout

Plan Start Date

Plan End Date

Client Goals (As stated in the NDIS plan)

DISABILITY AND HEALTH INFORMATION

Primary and/or Secondary Disability *

Are there any disability or health related risk factors that our staff need to be made aware of? *

High falls risk
Unaddressed incontinence
Absence of hygiene supports
Not yet engaged with support services (e.g. no support workers)
PPE required when visiting?
Other (any other potential risk factors, please describe below under "Are there any issues our visiting staff should be aware of?")

Please tick the services required *

Early Childhood Intervention Support (0-9 Yrs)
Specialist Behaviour Support
Rehabilitation Counselling
Functional Capacity Assessment
Occupational Therapy
Support Coordination
Psychology

Consultation Preference *

Home visits
Telehealth (online)

Total Support Hours Requested *

For ongoing therapy services, please select your preferred frequency *

Home Risk Assessment

Do you consent to home visits? *

What type of dwelling do you live in? (house, flat, unit, facility, caravan park, other) *

Are there any issues our visiting staff should be aware of? *

Do you have room inside your home for visiting staff to conduct the meeting/appointment? *

How many people live at your house? *

Do you, or anyone that may be present, have a history of concerning behaviours, drug and/or alcohol issues, or physical/verbal violence and aggression towards others? *

Do you have any weapons or firearms at home? *

Do you, or anyone that may be present, have any infectious diseases? *

Are there any animals on your property? If yes, what are they? *

Are there any concerns with neighbouring properties?

Do you have phone/internet reception in your home? *

How did you hear about us?

Please upload a copy of your NDIS plan, NDIS goals and/or any other relevant documents such as reports from other health professionals

Click or drag a file to this area to upload.

Upload More

Click or drag a file to this area to upload.

Contact Us

Get in Touch

Email

Phone Number

Quick links

Services

Address info

Follow us

Client Details

Client Representative Details (Parent/Guardian/Support Coordinator/LAC)

NDIS Details

DISABILITY AND HEALTH INFORMATION

Home Risk Assessment

Contact Us

Get in Touch

Email

Phone Number

Quick links

Services

Address info

Follow us

Make a referral

Client Details

Client Representative Details (Parent/Guardian/Support Coordinator/LAC)

NDIS Details

DISABILITY AND HEALTH INFORMATION

Home Risk Assessment