Your Future Taking the Next Steps - Expression of Interest Form

YOUR FUTURE - TAKING THE NEXT STEPS

Expression of Interest
Program details

This program is for people aged 18 years and older who have left school. It will commence one day a week in 2025 on Friday, November 7 and will increase to three days a week (Wednesdays, Thursdays to Fridays, 9am to 3pm) commencing Wednesday, January 28, 2026.
I am interested in:
Funding
This program can be funded from a number of NDIS categories including:
- Finding and Keeping a Job;
- Increase Social and Community Participation; and/or
- Core Supports.
These and your support requirements including 1:1 or 1:2 ratios will be discussed with you as part of the application process.
Participant Details
Participant's Name

First NameLast Name
NDIS Number
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Start date of NDIS Plan

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
End date of NDIS Plan

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nominee Details
Parent/Nominee Name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.

NDIS Participant Plan Details
How is your plan 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.

I give permission to be contacted to advance this service request and discuss availability
Preferred contact person
Preferred method of communication
Should be Empty:

YOUR FUTURE - TAKING THE NEXT STEPS