NDIS Initial contact form
Participant's Name
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Participant's NDIS Number
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Participant's phone number
Participant's Date of Birth
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Participant's Street Adress
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Suburb
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Participant's Gender
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Participant's Email
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Plan start date
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Plan end date
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Participant's Regular GP
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ACCEPTED DIAGNOSIS (NDIS)
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Brief Description of Participant's needs?
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Participant's goals?
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Participant is looking for:
Physiotherapy
Exercise Physiology
Hydrotherapy (on site clinical pool)
Women's Health
Cancer Rehabilitation
Lymphoedema
Does your participant have any issues that may impact our care?
Seizures
Incontinence
Mood Outbursts or violent behaviour
Non-Verbal
Hearing Impaired
Vision Impaired
Allergies/environmental sensitivities
How is the participant's plan managed?
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Self Managed
Plan Managed
Agency Managed
The participant's IDL supports are:
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A stated support for physiotherapy
A stated support for exercise physiology
A stated support for both physiotherapy and exercise physiology
Flexible
If Plan Managed, who is managing the plan?
Contact details for plan manager
Is a Service Agreement required?
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Is the participant's plan subject to PACE funding periods?
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Yes
No
Please attach a copy of the participant's plan. No budget info required, however About Me, Diagnosis, IDL information and Goals appreciated. Providing this information will assist us with report writing and assessments as well as ensuring we are treating under NDIS guidelines.
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I am the;
Support Coordinator
Plan Manager
Participant
Participant's representative
Other
If Other, please let us know here
Are you the best contact for organising appointments with/for the participant?
Yes
No
If no, please advise the best contact for the participant
Your name
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Your email:
Your phone number
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