Service Request Form

Who will be filling out this form today?* This field is required.

Enter the name of the person filling out this form and their relationship to you. If it is for yourself, please enter NA

I am interested in the following service(s)* This field is required.You can choose multiple services

Support Coordination

Plan Management

Disability/Care Support Services

Respite

SIL (Supported Independent Living )

MTA (Medium Term Accommodation)

STA (Short Term Accommodation)

ILO

Accommodation and Tenancy

Assist Access/Maintain Employment

Household Tasks

Community Participation

Specialised Disability Accommodation (SDA)

Other

Name* This field is required.

Prefix

First Name

Middle Name

Last Name

Date of Birth* This field is required.e.g. 13/02/1980

Date

Address* This field is required.

Street Address

City

State

Postcode

Country

Phone Number* This field is required.

Phone Number

EmailIf you do not have an email address, and have someone assisting you, ask them to enter their email address.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Is your NDIS Plan currently on PACE?Care Legion's Provider Number is 4050091425 please call the NDIS on 1800 800 110 to nominate us as your provider for the support you want to receive from us, if you are a new to Care Legion

YESNO

NDIS Number* This field is required.43XXXXXXX

NDIS Plan Start Date* This field is required.

Date

NDIS Plan End Date* This field is required.

Date

Please Attach Your NDIS Plan

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Are you moving from another Service Provider to Care Legion* This field is required.

YESNO

If YES, please enter the details of your current Service ProviderPlease include name, website, email, and address if you know it. Also include the service that you access from the provider. If NO, enter NA

Is your NDIS Plan currently managed by another organisation? Please enter detailsInclude the name of the Plan Manager, their phone number and email address for invoice

I confirm that my details above are correct and I wish to appoint Care Legion as my Service Provider* This field is required.

YESNO

I understand and agree that Care Legion will charge the CURRENT price according to the NDIS Price Guidelines for the provision of support to me* This field is required.

YESNO

I give Care Legion the consent to share my details with service providers that we have discussed and that I need if requiredConsent is required to assist you broker support services if you want us to provide support coordination services or direct support to you

YESNO

I understand that I can nominate an advocate to act on my behalf and I will let Care Legion know whoAn advocate can be a family member, close friend. You can also see a list of advocacy organisations here https://valid.org.au/resources-and-media/resources/list-victorian-advocacy-organisations/

YESNO

Terms and ConditionsPlease download this document for your reference

Terms and Conditions* This field is required.Care Legion conforms to NDIA price guidelines at all times. All support items requested before, during, or after this agreement, will be charged at the current prices.

I agree to terms and conditions

This Agreement is valid for all the support you will receive from Care Legion until you may decide to leave. Would you prefer to sign a new agreement with every new plan you receive? (We will resend this link to you again then)

YESNO

Signature of the person filling this form* This field is required.

Clear

Would you like to participate in our internal NDIS Audit? * This field is required.It is not mandatory. It is a discussion around the quality of service you receive from us.

YESNO

How did you find out about us?

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Service Request Form