Elevate Life Mentoring

Intake Form

Please provide your details to complete the intake process.
Full Name*

First NameLast Name
Preferred name
Date of Birth*

MonthDayYear
Gender*

FemaleMaleNon-binaryPrefer not to sayOther
Pronouns (optional)

She/HerHe/HimThey/ThemPrefer not to sayOther
Is there anything important about your identity you would like me to be aware of to support you respectfully? (optional)
What language do you use at home?*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact name
Emergency Contact details
Relationship to participant
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
NDIS Number*
NDIS Plan Type (required)*

Self ManagedPlan ManagedNo funding/Other
If plan managed, what is their email?
If you have a Support Coordinator, add their name, organisation, phone/email
Preferred communication methods.*

Video call (FaceTime, Google Meet, Teams, Zoom etc)Text messaging (SMS)Email
Plan start date*

MonthDayYear
Date
Plan finish date*

MonthDayYear
Date
What are your goals that you want support with OR what services do you need from Elevate Life Mentoring? (if unsure, can chat together to discuss further)
Available funding for Assistance with Social, Economic and Community Participation
Put the balance of current funding or allocated funding
Available funding for Assistance with Social, Economic and Community Participation
Available funding for Increased Social and Community Participation.
Put the balance of current funding or allocated funding
Available funding for Increased Social and Community Participation.
Available funding for Finding a Job/Keeping a Job
Put the balance of current funding or allocated funding
Available funding for Finding a Job/Keeping a Job
Do you have any risks or support needs I should be aware or to support you safely? (optional)
Preferred days/times for sessions or contact.*

WeekdayWeekendMorningAfternoonEvening
How did you hear about Elevate Life Mentoring?
I consent to Elevate Life Mentoring collecting my information for service delivery and invoicing.*

Yes, I consentNo, I do not consent
I consent to Elevate Life Mentoring communicating with my Plan Manager and Support Coordinator.*

Yes, I consentNo, I do not consent
I understand Elevate Life Mentoring is a non-NDIS registered provider.*

Yes, I understandNo, I do not understand
I understand that cancellations with less than 2 clear business days notice may be charged in line with the NDIS Pricing Arrangements and for repeated cancellations may result in review or discontinuation of services.*

Yes, I understandNo, I do not understand
I understand invoices will be sent to my Plan Manager or myself and must be paid with in 14 days timeframe.*

Yes, I understandNo, I do not understand
I have read and agree to the Elevate Life Mentoring Service Agreement and NDIS Pricing.*

Yes, I agreeNo, I do not agree
Please upload your NDIS plan (if available) - can be PDF or image. You can also upload supporting documents.

Cancelof
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Intake Form