Mindful Yoga Care Terms

Your email*

Your phone*

Participant Name*

First NameLast Name

Participant Date Of Birth

Participant Date Of Birth*

Date

How is the participants funds managed? *

Participant NDIS number*

If not on NDIS please specify

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 additional details including if participant has done Yoga before, where participant would like support facilitated, any challenging behaviours, or behaviour support plan details, risk assessments or management strategies, relevant restrictive practices, allergies, cultural values, beliefs, or any additional details or risks that would help us provide services such as Allergies, dietary requirements, violent outbursts, triggers, risks in home etc...*

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

Does the participant have space in 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.

Please feel free to upload any additional details that would help us provide support such as NDIS plan or management plans (Optional)

Signature*

Date