NDIS Client Questionnaire
Please take a few minutes to fill out this short questionnaire and help us get to know your client's needs. We will contact you in the next 48 hours with our NDIS pricing and availability.
Tell us more about YOU:
Will you responsible for coordinating/liaising on behalf of for these lessons?
*
Yes
No
Are these funds Self-Managed or Plan-Managed?
Self Managed
Plan Managed
Other
I am a...
*
Please Select
NDIS CLIENT
SUPPORT WORKER
SUPPORT COORDINATOR
FAMILY MEMBER
FRIEND
OTHER
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If you ARE NOT the person responsible for coordinating these services, please pass-on this form to the relevant person and we'll communicate with them directly.
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Your Full Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Tell us more about your CLIENT:
Clients Full Name
Age
Preferred Pronoun/s (If any)
Is this person under 18 years of age?
*
Yes
No
What kind of disability/s does this person have?
*
Physical
Sensory
Intellectual
Developmental
Psychiatric
Neurological
Chronic Health Condition
Does this person require disability access?
*
Yes
No
Please share any details about these disability/s (if any) that might be relevant to us pairing yourself/your client with a suitable coach:
To help us prepare options for you, please give us a rough outline of yourself/your client availability? The more options the better! Please note we are closed on weekends. (Leave this BLANK if you are unsure):
Submit
Should be Empty: