Secret Agent Society Expression of Interest
Participant Details
Participant's Name
*
First Name
Last Name
NDIS Number
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Start date of NDIS Plan
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
End date of NDIS Plan
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominee Details
Parent/Nominee Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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NDIS Participant Plan Details
How is your plan managed?
*
Please Select
Plan Managed (Please provide details)
Self Managed
Agency Managed
Plan Manager name (if applicable)
Plan Manager email address
example@example.com
Plan Manager phone
Please enter a valid phone number.
Format: (000) 000-0000.
I give permission for Connextions to contact my Plan Manager in order to determine if funding is available and the relevant categories for the services I have requested, as well as to prepare a service agreement
Support Coordinator Name (if applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I give permission for ConneXtions to contact my Support Coordinator to support with the completion of the service agreement, funding details and categories.
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Education
School child attends
Does your child have a diagnosis and if so please, tell us a little about the participant and their needs. What would you like as an outcome of attending the program?
Services requested
Services and Supports
*
Rows
Terms
Preferred Day
Preferred time
Category
Funding approval
Secret Agent Society
Ages 8 - 12 $2600.01
Duration of the plan
Terms 1 & 2
Terms 3 & 4
Monday
Thursday
Yes
No
09: Increased Social
11- Improved Relationships
15: Increased Daily Living
PM approved
Self Managed
Self funded (Non NDIS)
I give permission to be contacted to advance this service request and discuss availability
Yes
No
Please sign
*
Submit
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