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Client details
Parent/Carer contact details
NDIS plan details
Supports needed
Your Child / Person in Your Care
First Name
Last Name
Preferred First Name / Nickname
Gender
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Male
Female
Other
Date of Birth
Does the client identify as:
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Aboriginal
Torres Strait Islander
Both
Neither
How did you hear about us?
- Please select one -
Word of Mouth
Health Care Professional
NDIS Professional
Google Search
Social Media
Other
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Parent/Carer Contact Details
First Name
Last Name
Phone Number
Email Address
Postal address
Address
City
State
Post Code
Relationship to Client
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Next
NDIS plan details
NDIS number
Plan start date
Plan end date
Plan management status (tick all that apply)
Agency (NDIA)
Plan-managed
Self-managed
What are your child/client's NDIS goals?
Plan management details (if applicable)
Organisation name
Organisation/contact email
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Supports Needed
I’m interested in (tick all that apply)
Dietitian support
Speech therapy support
Occupational therapy support
To help us understand your needs, how do you define the client's primary disability?
Acquired Brain Injury
ADHD
Adjustment Disorder
Alcohol Related
Alzheimers Disease
Amputation
Ankylosing Spondylitis
Anoxia/Hypoxia
Anxiety
Aphrasia
Arthrogryposis
Ataxia
Autism
Autism Spectrum disorder
Back Injury
Behavioural Disorder
Bi Polar affective Disorder
Blind
Cerebellar Degeneration
Cerebral Leukodystrophy
Cerebral Palsy
Cervical Spondylitis
Charcot-Marie-Tooth Disease
Chronic Disease
Conduct Disorder
Congenital Deformity
CVA
Deaf
Deafblind (dual disability)
Dementia
Depression
Developmental delay 0-5 yrs only
Dysphasia
Dyspraxia
Dystonia
Eating Disorder
Epilepsy
Expressive Disorder
Familial Spastic Paresis
Friedreichs Ataxia
Guillain Baree Syndrome
Guillain Barre Syndrome
Hearing
Higher Functioning Autism
HIV - related Brain Injury
Homocystinuria
Huntingtons Disease
Hyperopia (Long Sighted)
Impulse Control Disorder
Infection
Intellectual inc Down Syndrome
Language Disorder
Mild Hearing Loss
Mixed Receptive/Exp Disorder
Moderate Hearing Loss
Motor Neurone Disease
Multiple Sclerosis
Multi System Atrophy
Muscular Atrophy
Muscular Dystrophy
Myasthenia Gravis
Myopia (Short Sighted)
Neurofibromatosis
Neurological
Neuropathy
Nystagmus
Obsessive Compulsive Disorder
Oppositional Defiance Disorder
Osteo Arthritis
Osteogenesis Imperfecta
Other
Other Brain Injury
Other Neurological
Other Neurological
Other Physical
Other Psychiatric
Parkinsons Disease
Personality Disorder
Pervasive Developmental Disorder
Physical
Polymyositis
Post Polio Syndrome
Post Traumatic Stress Disorder
Profound Hearing Loss
Psychiatric
Psychosocial disability
Receptive Language Disorder
Rheumatoid Arthritis
Scheuermanns Disease
Schizophrenia
Scoliosis
Semantic/Pragmatic Disorder
Sleep Disorder
Specific Learning Disability / ADD
Speech
Spina Bifida
Spinal Cord Injury
Spinal Cord Stenosis
Spinocerebellar Degeneration
Strabismus
Stroke
Substance Abuse
Syringomyelia
THI - Assault
THI - Home/Recreation Accident
THI - MVA
THI - Other
THI - Pedestrian
THI - Work Accident
Tumour
Vision
Vision Impaired
VisionTHI - Pedestrian
Prader-Willi Syndrome
Chromosome 18 Deletion
Does the client currently receive any allied health services?
Are you looking for an assessment or therapy?
- Select -
Assessment
Therapy
Both
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Submit Form
Delivery Day and Time
NSW
Sydney Metro:
Monday overnight (12am-7am) or daytime (8am-6pm)
Greater Sydney:
Monday overnight (12am-7am) or daytime (8am-6pm)
Wollongong:
Monday daytime (8am-6pm) or Tuesday overnight (12am-7am)
Goulburn:
Friday daytime (8am-6pm)
Newcastle, Hunter Valley:
Tuesday overnight (12am-7am) or daytime (8am-6pm)
Central Coast:
Tuesday overnight (12am-7am) or daytime (8am-6pm)
Tweed Heads:
Monday daytime (8am-6pm)
Canberra:
Monday daytime 8am-6pm
VIC
Melbourne, Geelong:
Tuesday daytime (8am-6pm)
QLD
Gold Coast, Sunshine Coast:
Monday daytime (8am-6pm)
Brisbane, Ipswich:
Tuesday daytime (8am-6pm)
SA
Adelaide:
Tuesday daytime (8am-6pm)
Order Cut Off
Orders must be received by 5pm on Wednesday.
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