• NDIS Client Intake Form

    -Plan Managed

  •  

    Instructions

     

    1. Complete this intake form or ask your Support Co-Ordinator to assist you to do this.
    2. An In-home consultation will be organised. If you would like to proceed we will organise a date and time to attend your home.
    3. Invoices will be sent to your Plan Manager for payment and before/after photographs may be submitted to validate work.
  • Format: (0000) 000-000.
  • Preferred Contact Method*
  • I prefer you to contact...*
  • Date Of Birth*
     / /
  • When does your current NDIS Plan end?*
     - -
  • What type of funding do you currently have available / have budget remaining for?*
  • Which of the following days / times may suit for your home consultation/s? Please select all that apply.*
  • Are there any entry or exit points of your home that cannot be accessed or used safely? Please select one.
  • Are your smoke alarms currently working with batteries changed regularly? Please select one.*
  • When thinking about the spaces in my home, my priorities are: Please select all that apply.*
  • I would like assistance with these areas of my home: Please select all that apply.*
  • How often do you are items removed from the home via selling, donations, giving away or discarding? Please select one.*
  • Which of the following factors have contributed to the current state of your home? Please select all that apply.
  • I understand that Jodi Maree Interiors is not a Registered NDIS Provider and operates as an Un-Registered Provider. Jodi Maree Interiors complies with all NDIS Guidelines and the NDIS Code of Conduct.*
  • Who has completed this form?*
  • Should be Empty: