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Application Form for Services Request

Application Form for Services Request

Please fill in the form below as much as possible it will help us to better understand client’s requirement.

I am *ParticipantRelative or Friend of Participant

Personal details of the Participant

Name *

Email Address *

Phone *

NDIS Number *

Address *

Gender *MaleFemaleLGBTQIA

DOB *

Can we call you? *Yes Please Call MeNo Please Email Me

Best Time to Call *

Hours

Minutes

Medical Details

Primary Disability: *

Secondary Disability: *

Psychosocial Disability: *

Allergies:

Medical Conditions:

Contact Details

Doctor's Details

Doctor Name *

Doctor Phone or Mobile Number *

Doctor Email *

Practice Address *

Additional Contacts

Do you want to list any additional contacts?

Radio *YesNo

Additional Contact Name

Additional Contact Phone / Mobile Number

Additional Contact Email

Additional Contact Relationship to participant:

Fears, Phobias and Behaviour

Please describe any fears and phobias that impact participant behaviour

Please help us with how frustration is displayed in a physical manner. What does the person do? How can you tell when the person is getting upset? What is the best way to settle the person?

Assistance, Culture, Medication and Education

Please indicate if you are part of these Communities:AboriginalTSICALD

Is English your primary language at homeYesNo

Do you require an InterpreterYesNo

Please list the language(s) required

Please tell us of any communication methods you use

Assistance

Do you need transportation assistance?YesNo

What type of transportation support is required?

Do you need assistance from our staff with taking medication(s)YesNo

Please tell us of any effects and side effects of any medication(s)

Do you need assistance from our staff with eating and drinking?YesNo

Please tell us of any special dietary requirements and any food allergies

Do you need assistance with personal care?YesNo

Please tell us what you need help with

Are there any health issues that we should be aware of like Epilepsy, diabetes, etc.?YesNo

Please tell us about these issue and any precautions that are needed in day to day support

What lifetime events do you think are important for us to know about?

Other details

Are there any safety issues or requirements at home we need to know about? Include the number and type of pets.

Please provide any other information you think is relevant.

Service Request Schedule

How many days a week

How many hours a day?

When do you want to start?

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