Mindful Yoga Care Terms

Your email*

Your phone*

Participant Name*

First NameLast Name

Participant Date Of Birth

Participant Date Of Birth*

Date

Participant NDIS number*

If not on NDIS please specify

How is the participants funds managed? *

Please provide an invoice email for Plan Managed or Self Managed or Self Funded signups. If you don't know the Plan Manager invoice email please write the company.*

Please include plan manager invoices email if you know it if agency managed please specify.

Participants &/or plan nominee name & contact phone number *

Please include plan nominee name if applicable

Participant &/or plan nominee email address*

If same as above please write as above

Address of the participant *

Suburb*

Postcode*

Participant State*

Participant Diagnosis*

Participant Gender*

Please mention any challenging behaviours or cultural values or beliefs or risks that would help us provide services e.g Allergies, violent outbursts, triggers, risks in home etc...*

Would you like us to use Core or Capacity Building to deliver our service?*

Do you have space in your home to do Yoga?*

Availability for sessions or respite - please list days, times and preferred listed support providers from our directory*

Please enter days and times you are available. Please also enter potential carers you might like to work with from our directory.

Please tell us about your goals & what you are hoping to get out of the service.*

If filling out on behalf of a participant please specify the participants goals.

Signature*

Date