• Request for Home and Living Supports

    ABN: 55 637 079 620

  • Home and living supports can assist you to live independently, and improve your living, household and management, social, communication, and behavioural management skills.

    For more information on the types of Home and Living Supports you may be available to request, please view the following NDIS website: https://www.ndis.gov.au/participants/home-and-living

    Who can complete this form?
    Participants or a person acting on their behalf, such as a family member, friend, stakeholder or guardian. In this form we use the term ‘You’ and ‘Your’. This is referring to the NDIS participant.

    You can fill out this form electronically or print and complete it using a blue or black pen.

  • 1. Participant Details

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year

  • 2. Reason for this request

  • What is your main reason for this request? Mark 'Yes' for only the reasons that apply to you.
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  • 3. Current Living Arrangement

  • What is your current living arrangement? Mark 'Yes' for only the arrangement that best describes your situation in the table.
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  • 4. Housing and Living Support Goals

  • 4.2 Do you want to add this goal or another housing and living goal to your plan at plan review?

  • 5. Support to Help You

  • What housing and living supports will best help you to meet your goals? Mark 'Yes' only for the supports that you need.
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  • 6. Your Current Housing and Living Situation

  • 6.8 Do you receive assistance right now from a carer or support person?*
  • 6.8.1 Please tell us their details and what they do for you below:*
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  • 6.9 Is there anything else you would like to tell us about your current housing and living situation?*

  • 7. How You Manage Tasks

  • How do you manage everyday tasks? Please tell us your ability with the tasks listed below. Mark only one for each task listed.*
    Rows

  • 8. Your Health-care Needs

  • Do you need support with your health care needs? Please tell us by selecting 'Yes' only for the health care need(s) that apply to you.
    Rows

  • 9. Assessments and Reports

  • 9.1 Have you completed or had a review of any of the plans or programs listed below in the last 12 months? Select 'Yes' only for those that apply to you.
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  • 9.2 Have you completed or had a review of a plan or program that was not listed above?*

  • 10. Assistive Technology and Home Modifications

  • 10.1 Do you currently use assistive technology or equipment?*
  • 10.2 Have you had any home modifications done in the past?*

  • 11. Your Decision-making

  • 11.1 Do you receive any help with decision-making?*
  • 11.1.1 Please tell us who helps you below:
    Rows
  • 11.1.2 What is your relationship with this person? Please mark the relevant box below:*
  • 11.2 Did you receive any help with completing this form?*
  • 11.2.1 Please tell us who has helped you below:*
    Rows
  • 11.2.2 What is your relationship with this person?*

  • 12. Participant Consent

    This is the consent you provide to the person(s) you have listed in part 11 of this form.
  • 12.1 What information, if any, do you give consent to share with this person? Please mark the relevant boxes below:*
  • 12.2 What actions, if any, do you give consent for this person to do on your behalf?*
  • 12.3 What is the reason, if any, you are providing this person with consent?*
  • 12.5 What length of time, if any, are you providing the consent for?*

  • 13. Acknowledgement

  • Please indicate how this form has been completed:*

  • 13.1 Participant acknowledgement 

    Please note: NDIS participants have other options instead of signing here. If you are unable to sign here, you can direct someone aged 18 and over to sign, in the section below called ‘Delegate acknowledgement’. Someone else can also sign the ‘Delegate acknowledgement’ if you have provided consent for them to act on your behalf in part 12 above.

  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year

  • 13.2 Delegate acknowledgement.

    Please note: Please note: This section is only to be completed if the participant is unable to sign above. Instead, their chosen delegate must be aged 18 and over and can sign below.

  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • 13.2.1 What is your relationship with this person? Please mark the relevant box below:*
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  • Should be Empty: