Group Activities/Workshops Referral Form Finders Keepers WA

Finders Keepers Workshop Program of Support

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The National Disability Insurance Scheme (NDIS) Program of Support is a plan that outlines the supports and services an individual with a disability will receive through the NDIS.
Participant's Details:
Participant Name

First NameLast Name
Gender

MaleFemaleTransgenderNon-BinaryOther
Date of Birth

DayMonthYear
Date
Phone Number
NDIS Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Communication

Phone CallSMSEmail
Parent/Guardian Details (If applicable)
Parent/Guardian Name

First NameLast Name
Phone Number
Relationship
Support Providers
Support Coordinator (if applicable)
Name and Company
Phone Number
Please enter a valid phone number.
Email
example@example.com
Other service providers (if applicable)
Participant's Goals and Aspirations:
Goals
Skills, Talents, and Hobbies
Please upload your recent photo where possible

Cancelof
Participant's Support Needs
What program/s are you enrolling in?

Employment WorkshopCraft and Skills WorkshopWomen's Wellness Workshop
Please advise of disabilities, illnesses, allergies, medical conditions or personal concerns that staff need to be aware of, to best support the participant during the workshops?
Budget Allocation
Each Program Runs for up to 10 weeks at a 1:4 Ratio utilising core or capacity building funding.

Cancellation Clause: A program of support is an arrangement where a group-based support provider enters into an agreement with a Participant for up to 12 weeks. During this arrangement, supports in the program can be claimed against the Participant’s plan regardless of whether they attended.

Services that are operating under a program of supports approach are not subject to short notice cancellation rules. To exit the program of support, no more than 2 weeks of notice is required. 100% of the scheduled fee can be charged for sessions taking place during the 2-week notice period. The cost of sessions due to take place after the notice period will not be charged.
How is your funding managed?
Plan/Self-management email (if required)
Plan Start Date

DayMonthYear
Date
Plan End Date

DayMonthYear
Date
I authorise the use of my photographs, videos or voice for marketing purposes

YesNo
How did you learn about our Workshops?

FacebookFrom Your Friends and FamilyFrom Your Support CoordinatorNDIS EventsFrom Our Service Coordinator or Employment PractitionerOther
Any additional comments or information you would like to share?
Participant Agreement
I, confirm that the goals, support needs, and budget allocations outlined in this Program of Support accurately reflect my preferences and requirements. I understand that this document will be reviewed periodically to ensure it remains aligned with my evolving needs and aspirations.

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Date Signed

MonthDayYear
Date
Should be Empty:

Finders Keepers Workshop Program of Support

Participant's Details:

Parent/Guardian Details (If applicable)

Support Providers

Participant's Goals and Aspirations:

Participant's Support Needs

Budget Allocation

Participant Agreement