Referrer's Details

Your name *

Your Email *

Who's referring? Your relationship to the client *

N/A. I am the client and am self referring

Support coordinator

Parent / guardian

Other

Participant Details

Full Name *

NDIS - Number *

Date of birth *

Phone

Address *

Participant's medical history and relevant diagnoses / disabilities *

Service & Plan Details

NDIS Goals (If plan has been finalised)

Plan Dates

Where would you like to meet? *

East Brisbane Clinic

Home visit

Online (Google Meet)

Unsure

Do you have any stimulation preferences?

Being able to wait in my car for my appointment

Dim / turn off the light

Floor sitting options

Access to fidgets

Have the aircon turned off

Have the aircon turned on

Bringing a support person with you

Bringing a support dog with you

Having access to a white board to communicate

Are support staff / family / friends are likely to be present at sessions? Please let us know their names and relationship to the client. *

Is there anything you'd like us to know?

Safety

For the safety of the participant and providers, should we be aware of any of the following?

History of:

Physical and/or verbal abuse to providers

Aggressive household members or animals

Unsafe environments at the participant's property

Discriminatory behaviour or racism

Current drug and alcohol abuse

Any known bloodborne or transmissible diseases (e.g. HIV, Hepatitis C, etc)?

Other:

If 'yes' to any of the above, please provide more details:

Invoicing

How are supports managed? *

Plan Managed

Self Managed

Agency Managed

What is the best email to invoice? *

What is the proposed budget for this service? *

Communication

Please let us know the best email to receive appointment updates and service agreements: *