NDIS Service Request Form

NDIS Service Request Form
The information provided in this form will assist Simply Stronger Exercise Physiology in organising an appropriate and effective exercise assessment and prescription, which may include face to face exercise appointments with an Exercise Physiologist or the design of an exercise program for the client to complete with a family member, support worker or buddy. Once this form has been submitted, an Exercise Physiologist will contact you to answer any questions and book your initial assessment.
Personal Information
Client's Name*

PrefixFirst NameLast Name
NDIS Number*
Plan Start Date*

DayMonthYear
Plan End Date*

DayMonthYear
Living Situation*
Email Address*
example@example.com
Contact Number*
Phone Number
Date of Birth*

DayMonthYear
Gender*
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Secondary Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Advocate or Guardian Information
Does the client have an advocate or guardian?*

YesNo
Advocate or Guardian's Name*

PrefixFirst NameLast Name
Relationship to Client*
Contact Number*
Phone Number
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Emergency Contact Information
Is the particpants emergency contact different to their advocate or guardian

YesNoNo, but I would like to add a secondary emergency contact
Emergency Contact's Full Name*

PrefixFirst NameLast Name
Relationship to Client*
Email Address*
example@example.com
Contact Number*
Phone Number
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Support Coordinator Information
Does the client have a Support Coordinator?*

YesNo
Support Coordinator*

First NameLast Name
Organisation*
Contract Number*
Email*
example@example.com
NDIS Fund and Plan Management
Is the client's NDIS fund:*

Self-ManagedNDIA Portal ManagedManaged through a Plan Management Provider
NDIS Support Category*

Capacity Building - Improved Daily Living 15_200_0128_1_3Capacity Building - Improved Health and Wellbeing 12_027_0126_3_3Early Childhood Supports - Exercise Physiologist 15_609_0118_1_3
Plan Manager
Organisation
Email
example@example.com
Would you like invoices sent to the above address?

YesNo
Alternate Invoice Email Address - if required
example@example.com
Participant's Current Health Capabilities
Is the client currently taking any medications?*

YesNo
Please provide additional details:*
Age/Life Stage*
Formal Diagnosis*
Secondary Diagnosis
Impact of formal diagnosis on daily function*

AlwaysOftenSometimesRarelyNever
Guidance for positive interactions

Please provide details to aid our exercise physiologist in creating positive interactions with the client. Details may include:
- Mobility constraints
- Sensory constraints
- Behavioural constraints
- Social considerations
- Support worker or buddy
- Previous exposure to organised physical activity or exercise.
Please provide details for positive interactions here:*
Simply Stronger aims to be a fully accessible space for all participants.

Please provide details of any access requirements. These may by physcial requirements such as ramps or sensory requirements such as a quiet space.
Access requirements
Participant's Goals

Please list the client's NDIS plan goals as well as exercise specific goals.
Goal 1*
Goal 2
Goal 3
Goal 4
Goal 5
Anticipated Schedule of Supports
Appointment type*

On site at Simply Stronger Exercise PhysiologyHome visitAnother locationCombination of onsite and home visitsUnsure at this stage
Secondary address where the appointments will take place (ie. a day centre)?*

YesNo
Frequency*
How often per week, fortnight or month?
Duration*
Total amount of services (e.g. 30 weeks/appointments)
Preferred Time and Day
Monday:*

MorningAfternoonEveningUnavailable
Tuesday:*

MorningAfternoonEveningUnavailable
Wednesday:*

MorningAfternoonEveningUnavailable
Thursday:*

MorningAfternoonEveningUnavailable
Friday:*

MorningAfternoonEveningUnavailable
Saturday:*

MorningAfternoonEveningUnavailable
Sunday:*

MorningAfternoonEveningUnavailable
Simply Stronger Exercise Physiology Service
Simply Stronger’s accredited exercise physiologists offer 1:1 exercise prescription and delivery for NDIS clients in a variety of locations based on the individual needs. These sessions can be completed on site are 61 Hawthorn Road, Caulfield North, in Simply Stronger’s Studio, accessible via a 10cm step or use our lego ramp which we’ll put out the front before you arrive. We have two exercise rooms, the main gym space accessed via the small step or lego ramp and a second private smaller room available for those who need a quiet/private space. This second room is on the first floor requiring stair climbing to access. It is also important to note our bathroom is disability friendly, accessed via another ramp or three steps. Both exercise rooms have aerobic, resistance and pilates equipment along with a range of fun and engaging small pieces of equipment. We also support clients within their own environments be that at their home, day centre, supported accommodation, or local gym/pool.

Initial Assessment (90mins):
This 90min session is broken into 60min face to face with your Exercise Physiologist discussing your medical and physical activity history, your goals and completing any assessments. We will use a further 30min building your treatment plan, chatting with your support coordinator or other supports, reading through reports and working out funding options as required. The participant is only required to attend the first 60min face to face part of this session.

Subsequent Sessions (60, 45 or 30mins):
Subsequent sessions are available as 30, 45 or 60min sessions. Allowing flexibility to suit your exercise needs and funding availability.

Home Visitations:
Any session conducted offsite from Simply Stronger’s premises are considered to be a “home visitation” whether this be at the client’s home, day centre or other location. These home visitations will attract an additional charge of $6.96 per 5min of travel up to 30min in each direction. In circumstances where travel time is greater than 30min due to distance, traffic or another unforeseen circumstance, the session may be shortened to accommodate for this. Further if sessions are conducted at an alternate premise (gym or swimming pool) any access or entry charge for the practitioner will be charged to the client in addition to their session charge.

Costings:

At Simply Stronger
Initial assessment (90min) $237
Subsequent session (60min) $137
Subsequent session (45min) $116
Subsequent session (30min) $100

Home visitation
Travel per 5min block $6.96

Program review $60
Note: this can be waived for clients seen on a weekly, ongoing basis.

Report writing and team meetings $165/hr
Eg End of Plan/Service report, Request for service report, additional letters/reports to other medical professionals
I have read and agree to the service information explained above*

Yes
Future Contact
This form was completed by

The NDIS participant.The Support Coordinator of the NDIS participant, listed above.The Advocate of the NDIS participant, listed above.Other
Who shall we contact to discuss further details?

The NDIS participant themselves.The Support Coordinator listed.The Advocate listed.Other
Who shall we contact to book future appointments?

The NDIS participant themselves.The Support Coordinator listed.The Advocate listed.Other
Cancellation Policy
Please be aware Simply Stronger requires a minimum of 24 hours’ notice for any change or cancellation of your appointment. In the event of less than 24 hours’ notice being given you will be charged the full fee of the appointment. By signing this form you acknowledge having read and accepted this policy.
Please indicate below that you have read and understand Simply Stronger's cancellation policy*

Yes
Supporting Documents
Please upload any additional files here

Browse Files

Cancelof
Should be Empty:

NDIS Service Request Form

Personal Information

Advocate or Guardian Information

Emergency Contact Information

Support Coordinator Information

NDIS Fund and Plan Management

Participant's Current Health Capabilities

Participant's Goals

Anticipated Schedule of Supports

Preferred Time and Day

Simply Stronger Exercise Physiology Service

Future Contact

Cancellation Policy

Supporting Documents