Request Form

Client's Full Name *

Contact Number *

Client Date of Birth *

NDIS Number/Reference Number *

NDIS Plan Start Date

NDIS Plan End Date

Client Email Address:

Client language and cultural background

How did you hear about us? *

Health and Medical Information

Please enlist Client's medical condition and disability. *

Please Enlist Allergies/Alerts

Medication support required

Yes, Medication administration is requiredYes, Requires assistance and promptingNo, Not required any supports or assistance

Does the individual have any mobility issues/concerns *

YesNo

Are there any behavioural concerns. *

YesNo

Does participant have a Behaviour Support Plan *

YesNo

Are You a support Coordinator *

YesNo

Support Coordinator Full Name *

Support Coordinator's Organisation *

Support Coordinator's Contact #: *

Support Coordinator's Email Address *

Who is the Service for? *

Claim Number *

Who Manages your Plan? *

Agency ManagedPlan ManagedSelf Managed

Plan Managing entity/business

Client Address *

Suburb *

State *

Postcode *

Who are the Supports and Services for? *

Child/Adolescent Under 18Adult under 65Senior above 65

Participant Age Group *

4-7 years old8-14 years old15-18 Years old

Detail any other services expected under service agreement that contribute to your goals and independence ?

Comments about Support needs & Schedules

Select Date you wish to start services *

Please Specify Time/Hours

I agree for Carepro Disability Service to handle and store my information.

Information pertaining to service user/Clients is Confidential. Discussion of matters relating to service Users/Clients is to be confined to the appropriate areas of concern as required by law. Written and informed consent must be obtained from clients before any information is released to third parties including family.

This information should only be accessed, discussed, used or disclosed for the purposes of these activities (of providing a quotations and service aggreement). Personal client information is not to be discussed outside of the organisation. No inappropriate or unnecessary discussion about clients is to occur.

Company Declaration

Carepro Disability Service, understands and hereby agree that information gained whilst Requesting service agreement is at all-time strictly confidential and no unauthorized access, discussion, use or disclosure shall take place.

The information is gathered as part of assessment and is seen by support workers and management. The information is retained in order to document what happens during the service plan.

we understand that any violation of client privacy or confidentiality is considered breach to the company registeration aggreement as per ndis quality and safegard commission.

All personal information gathered by the Support worker during the service plan will remain confidential unless:

It has been subpoenaed by a court or authorised by law.
Failure to do so would place you or another person at serious risk
Your prior approval has been obtained.

*

Attach NDIS Plan or other relevant documents.

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