NDIS Funding Application Form

NDIS Funding Application Form

Apply for NDIS support by completing this easy-to-follow application form. Please answer all questions and upload any supporting documents.
Applicant Details

Tell us about the person applying for NDIS funding.
Full Name*

First NameLast Name
Date of Birth (You must be under 65 on the day you apply)*

MonthDayYear
Date
MyselfOn behalf of someone else
If applying on behalf of someone else, please provide your name and relationship to the applicant
Current Residential Address (You must live in Australia)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
What is your citizenship or visa status?*
If you selected "Other / Not sure", please provide details
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
NoYes
If yes, please tell us what language or support you need
NoAboriginalTorres Strait IslanderBothPrefer not to say
Disability and Support Needs

Help us understand your situation and support needs.
YesNoNot sure
Describe your main impairment(s) or condition(s)
How long have you had this impairment or condition?
YesNoNot sure
How does your impairment affect your daily life? (moving around, communicating, socialising, learning, self-care, self-management)
Does your impairment affect your ability to work, study or take part in social activities? If yes, please describe how.
YesNoNot sure
Are you seeking support mainly under the disability requirements, early intervention, or both?
If you are seeking early intervention, how do you think early supports will help you now and in the future?
YesNo
If yes, please describe the developmental delay and how it affects the child’s daily activities.
Do you currently receive any supports (for example, from health services, community services, school, or other government programs)?
What NDIS-type supports do you think you need? (for example, therapies, equipment, help with daily activities, support to participate in the community)
Is there anything else about your situation you would like us to know?
I give consent for the NDIS to contact and obtain information from relevant services to help assess this application.
Upload any supporting documents or reports from health or allied health professionals

Cancelof
Signature of applicant or authorised representative*
Name of person signing*
Date signed*

MonthDayYear
Date
Should be Empty:

NDIS Funding Application Form

Applicant Details

Disability and Support Needs