NDIS Support Coordination Intake Form

Title

First Name

Surname

Preferred Name

Date of Birth

Gender

Phone (Home)

Phone (Mobile)

Email

Residential Address

Postal Address (if different)

Living Situation

Living Alone Partner Carer Parent Children Shared Other (Specify)

Language at Home (other than English)

Interpreter Required?

Yes No

Preferred Method of Communication

Aboriginal/Torres Strait Islander Origin

Yes No

Disability Diagnosis

Nominated Support Person

Name

Relationship to Participant

Residential Address

Postal Address (if different)

Home Phone

Mobile

Email

NDIS Plan Details

Reference Number

Plan Dates

Plan Manager Details (if applicable)

Contact Name

Phone Number

Email Address

Self Managed Details (if applicable)

Contact Name

Phone Number

Email Address

Service Request

Funding Allocation

Funding Management

Support Coordination

Level 1 Support Connection Level 2 Coordination of Supports Level 3 Specialist Support Coordination

NDIS Plan

Copy attached

Yes No

Collection of Personal Information and Consent

Holistic Professional Services collects and retains personal information (such as your name, date of birth, address and personal needs) so that we may provide you with services. This information may be disclosed between the NDIA and its partner agencies and other service providers that may be able to provide you with support services. Unless authorised or required by law, your personal information will not otherwise be disclosed to any other third party without your consent.

Staff will only collect relevant personal information to:

Provide quality services
Carry out the functions, supports, and activities on behalf of the organisation
Meet our statutory, licensing, regulatory, or legal requirements

Staff shall not disclose or use personal information without the consent of the individual and/or appointed guardian/administrator without the specific written consent of the customer/guardian.

I consent for Holistic Professional Services to collect the above personal information and to create service bookings on my behalf as the Participant (for NDIS/Agency managed plans only).

I give my consent

Client Information

Name of Client or Client Representative

Signature

Date