NDIS Intake Form

NDIS Intake Form
Participant Details
Name*

First NameLast Name
Date Of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Aboriginal/TSI

YesNo
Contact Name (Carer/Guardian, agent)

First NameLast Name
Email Address
Contact Phone Number
Please enter a valid phone number.
Who Is Your Decision Maker

First NameLast Name
Decision Maker Phone Number
Please enter a valid phone number.
How did you hear about us?
NDIS Information
NDIS Participant Number
Is There A Current Plan In Place

YesNo
Plan Start Date

DayMonthYear
Date
Plan End Date

DayMonthYear
Date
Plan Management
Company Name
Support Coordinator
Support Coordinator Name
Support Coordination Company
Request Details
Request Date

DayMonthYear
Date
What are you requesting from Birrang

Support Requirements
Cultural or Religious Sensibilities
Staff Compatibility
E.g. Male/ Female, Age, Culture, Ethnic Background
Medical Information that may contribute to a medical emergency?
Current Supports
Notes

Complaints
If the Participant wishes to give the Provider feedback, the Participant can talk to Birrang CEO on 02 6361 9511 or email: tim.smith@birrang.com.au. If the Participant is not happy with the provision of supports and wishes to make a complaint, the Participant can talk to Birrang CEO on 02 6361 9511 or email: tim.smith@birrang.com.au. If the Participant is not satisfied or does not want to talk to this person, the Participant can contact the National Disability Insurance Agency

NDIS Quality and safeguards commission,

Web: www.ndiscommission.gov.au,

Phone: 1800 035 544 or TTY 133 677.

Interpreters can be arranged.

Rights of Participants

Birrang aims to uphold the rights of people with a disability including the right to dignity and respect, and to live free from abuse, exploitation, and violence. This is in keeping with the NDIA’s commitment to the United Nations convention on the rights of persons with disabilities.

Your Rights	We Will	Your Responsibilities
Access to quality services	Give you access and choice to services that meet your needs	To tell us if your needs change
Safety and care under Birrang support	Provide safe and appropriate care and services	Act in a way that keeps you and our staff safe
Treated with respect, dignity, and courtesy	Be polite and respect your views, opinions, and personal circumstances such as your culture, family situation, age, gender, disability, faith, sexual orientation, gender identity or intersex status.	To respect our property and other people using add services
Information Sharing	Provide information that meets your needs in a way that you understand	To give us complete and accurate information regarding your needs
Deciding what happens and when	Include you in decisions about services and treatment options and allow you to bring another person to speak on your behalf	Consider following the service and care plans that are given to you and make the decisions that are right for you
Privacy and confidentiality	Protect your personal information and only use it for the right reasons	To value the privacy of others attending programmes and services
Feedback and Complaints	Tell you how you can give us feedback	Give as honest feedback to help us improve or let us know when we do a good job

I First Name Last Name understand that I have a freedom of choice with providers with my NDIS plan.
I have been informed that there are other providers can facilitate the supports listed in my plan. Plan Management (PM), Support Coordination (SC) and Support Work (SW).
I am aware that Birrang Enterprise does not have to manage all aspects of my NDIS plan and that multiple companies can work together for me and my NDIS plan implementation.
I confirm that I have freely made the choice for both my PM, SC and SW and have not been influenced by Birrang staff to have any or all services under Birrang Enterprise.
Signature

Clear
If you have a copy of your NDIS Plan please attach it in here

Cancelof

	Yes	No
NDIS / NDIA
NDIA Quality and Safeguards Commission
Guardian Legal Representative Family
Accommodation and Housing Providers (Including DoH and Private Rentals)
Other NDIS Service Providers
Health Management Teams
Allied Health Mental Health Teams
Educational Organisations
Other Government Organisations
Correction Legal Services
Employment Services

NDIS Intake Form

Participant Details

NDIS Information

Request Details

Support Requirements

Complaints

Rights of Participants

Consent to Exchange Information