Participant INTAKE:

Participant INTAKE:
Diverse Learning We pride ourselves on being "diverse by name, diverse by nature" and feel that a unique successful working relationship is imperative in obtaining optimal outcomes.
Name

First NameLast Name
ADDRESS
Date of Birth
Phone Number
Please enter a valid phone number.
E MAIL
example@example.com
NDIS Number if known:
Services you are requesting

L2 Support CoordinationSpecialist Support CoordinationPositive behaviour SupportDevelopmental EducationTeam leader/key workerSupport work (daily activities)Support work (community Access)Psycho-social recovery coachingOutdoor connections (program)Other
Frequency
Goals/desired outcomes
Why do you think Diverse will be a fit for you?
Primary Diagnosis under NDIS
Are there any other Diagnoses or Co-occurring conditions? (Please explain below)
Current NDIS supports/Therapies?
Are there any Government Agencies involved?
If so, please list below.
Are there any Court Orders, Guardianship or Power of Attorney in place?
Please briefly describe below.
Any other information you would like us to know about you or your family? Ie; Restrictive practice, medication administration, complex care needs or accessibility requirements etc
Should be Empty: