Proposal - Reengagement Form

NDIS Re-Engagement Form

Complete this form if yourself or a participant are re-engaging or continuing in services with Healthstyles. Includes required fields*
Participant Details
Participant Name*

First NameLast Name
Participant Birth Date

DayMonthYear
Participant Phone Number
Participant's phone number (if applicable)
Participant Address*

Street Address

Street Address Line 2

CityState

Post Code
Referral Agency
Name of referring agency (if applicable)
Coordinator of Supports:

First NameLast Name
Coordinator Contact Number:
Mobile or landline
Coordinator E-mail Address:
example@example.com
Disability/Diagnoses/Support Requirements/Notes:
NDIS Funding and Support Requirements
NDIS Number:*
8 characters in length
Plan Start Date*

DayMonthYear
Plan End Date*

DayMonthYear
Funding Type:*

NDIS ManagedSelf-ManagedPlan Managed
If self-managed/plan managed, please provide details for invoices below:
Plan Manager Name/Agency:
Billing E-mail:
example@example.com
Additional details (if required):
Service Required (choose one or more)*

Behaviour Assessment & Plan - A behaviour specialist will be engaged to complete assessment, offer training, and complete a report based on behaviours of concern listed in the referral.Assessment e.g. Cognitive, Screen - A psychologist or behaviour specialist will be engaged to conduct an assessment using standardised assessments tools to identify needs.Early Childhood Intervention - The Allied Health Specialist will be engaged to complete a support plan for individuals aged between 0-7 years.Therapy/Counselling - A member of the The Allied Health team (Social Worker or Psychologist) will be engaged to complete a therapy program with the participant to address their presenting concern.
Line Item*
Has the plan been separated into quarterly funding periods?*

YesNo
Quarterly funding details:
Service Agreement

Please note: Service Agreement is required to be completed at or prior to commencement of services, and that the initial engagement is covered by the consents below.
Consent
Has Healthstyles Allied Health Clinic been granted consent to engage in services:*

YesNo
Has Healthstyles Allied Health Clinic been granted consent to complete a service booking:*

YesNo
Has consent to share this information with Healthstyles been obtained from the participant?*

YesNo
Supporting documents:

Plans, reports, logs, request for service etc
Cancelof
Should be Empty:

NDIS Re-Engagement Form

Participant Details

NDIS Funding and Support Requirements

Service Agreement

Consent