Your Email
*
example@example.com
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
Participant NDIS Number if applicable
*
Please specify if you're not an NDIS participant
How are the participants funds managed?
*
Please Select
Plan Managed
Self Managed
Agency Managed
Not on the NDIS
Invoice email for self managed or self funded & plan managed clients. If agency managed please specify.
*
Please include invoice
Participants &/or plan nominee name & contact phone number
*
Participant &/or plan nominee email address
*
Address of the participant
*
Participant Suburb
*
Participant Postcode
*
Participant State
*
Please Select
NSW
QLD
WA
SA
VIC
CAN
TAS
NT
Participant Diagnosis
*
Participant Gender
*
Please mention any additional details suchas as local gym including if participant has been their before 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 or specific emergency management requirements etc...
*
Would you like us to use Core or Capacity Building to deliver our service?
*
Please Select
Core
Capacity Building
If the budget selected isn't available and services are delivered we will use budget available from categories within the service agreement.
What type of support would you like delivered ?
*
Please Select
Local community venue eg local gym, park, pool for fitness support
Support attending and participating in a local fitness class
In home fitness support
Availability for sessions or respite - please list days, times and where participant would like support to be facilitated
*
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)
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