NDIS Client Application Form

Date of referral *

Client Details

First Name *

Last Name *

Date of Birth *

Pronouns

She/her/hersHe/him/hisThey/them/theirs

Address *Please include the postcode

Mobile Number *

Additional Phone Number

Email *

Medical Diagnoses *Please put a * on the end of the NDIS funded diagnoses. For example, Cerebral Palsy*.

NDIS Number *

Start Date of Current NDIS Plan *

Review Date of Current NDIS Plan *

How is the client's 'improved daily living' funding managed? *

Agency ManagedPlan ManagedSelf-Managed

Plan Manager Name (if applicable) *Please write 'N/A' if the client does not receive plan management support

Plan Manager Email *Please write 'N/A' if the client does not receive plan management support

Current goals as stated on the client's current NDIS Plan *We will be unable to proceed with the referral without the current goals as stated on the client's current NDIS Plan

Client Nominee

Name

Mobile

Client Nominee Email

Application Information

Service requested *

Complex Home Modifications Functional Assessment and Report (Review)Functional Assessment and Report (SIL)Functional Assessment and Report (SDA)Life Skills Therapy ProgramEmotional Wellbeing Therapy Program (including EFT and nature therapy)General Therapy ProgramOther

If you noted 'other' above, please provide details

Best way to organise appointments with the client *

If you noted other above, please provide details *Please write 'N/A' if you did not tick 'other' above

Applicant Details

Name *

Organisation *

Mobile *

Relationship to client above *

Referrer Email *

Provision of Information

Is there anything else you think is important we know at this stage?

You're welcome to attach documents with the client's consent, including the client's NDIS Plan and relevant medical and allied health documentation

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