Prismatic Care Expression of Interest Form

Expression of Interest Form

Join the Prismatic Care Community
Thank you for your interest in Prismatic Care. Please complete this form to help us understand your needs and how we can best support you.

Completing this form does not commit you to a service, but it helps us start the conversation.
Personal Details

Please fill out below
Name

First NameLast Name
D.O.B.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
NDIS Details

Please fill out below
Primary Disability
if multiple please list all
NDIS Number
How is your Funding Managed?
Plan Manager
Please list Plan Manager name or Email
Requested Services

Please fill out below
Which supports are you looking for?
When do you need Support?
e.g Monday Mornings, Weekday Supports
Diversity and Inclusion

Please fill out below
What language is spoken at home?
Do you require an interpreter?
Are there specific cultural or religious practices we should be aware of when supporting you?
e.g. dietary needs, home etiquette, prayer times
Would you like to share your preferred pronouns?
e.g. He/Him, She/Her, They/Them
Is it important to you that your support worker is a member or a proactive ally of the LGBTQIA+ community?
Is there anything else regarding your identity you would like us to know to ensure you feel safe and respected?
Consent and Submission

Please fill out and sign below
I confirm that the information provided above is true and correct to the best of my knowledge.
Name of Person Completing Form?
Relationship to Applicant:

Other
Signature
Should be Empty:

Expression of Interest Form

Personal Details

NDIS Details

Requested Services

Diversity and Inclusion

Consent and Submission