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NDIS Application Form
NDIS Application Form
NDIS Application Form
Please complete this form in 4 stages
1
Client Details & Services
2
Emergency Contacts
3
Plan Manager and Referrer Information
4
Installation Options
Client Details & Services
Client Details
Title
*
*
First Name
*
*
Last Name
*
*
Date Of Birth
*
*
Email Address
*
*
*
Home Phone Number
*
*
Mobile Phone Number
*
*
Address 1
*
*
Address 2
*
City
*
*
Postcode
*
*
State
*
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Services and Payment
Type of Service Required
*
Home Only
Home and Mobile
Solo Watch
Home and Solo Watch
MePACS Solo Watch
40mm Cream Gold Watch
40mm Graphite Watch
44mm Graphite Watch
The client has good Telstra Mobile Phone coverage in their home
I can confirm
The watch needs to be charged regularly and I/the client is able to operate touch screen technology
I understand
Additional services
Additional Pendant
Additional Pendant
No
Additional Pendant
Yes
Jelly Bean
Jelly Bean
No
Jelly Bean
Yes
Daily Call
Daily Call
No
Daily Call
Yes
Vibrating pendant
Vibrating pendant
No
Vibrating pendant
Yes
Key Lock
Key Lock
No
Key Lock
Yes
Arthritic Sleeve
Arthritic Sleeve
No
Arthritic Sleeve
Yes
Accessories
*
Heath Details
Type of Disability or condition
Multiple Sclerosis
Cerebral Palsy
ABI
Epilepsy
Cystic Fibrosis
Spina Bifida
Muscular Dystrophy
Musculoskeletal
Psychosocial
Neurological
Autism
Fully Vaccinated for COVID
*
Fully Vaccinated for COVID
No
Fully Vaccinated for COVID
Yes
Does the client have problems with: (Tick all that apply).
Hearing
Hearing
No
Hearing
Yes
Memory
Memory
No
Memory
Yes
Allergies
Allergies
No
Allergies
Yes
Falls
Falls
No
Falls
Yes
Speech
Speech
No
Speech
Yes
Heart Disease
Heart Disease
No
Heart Disease
Yes
Asthma / Airways
Asthma / Airways
No
Asthma / Airways
Yes
Vision
Vision
No
Vision
Yes
Mobility
Mobility
No
Mobility
Yes
Diabetes T1
Diabetes T1
No
Diabetes T1
Yes
Diabetes T2
Diabetes T2
No
Diabetes T2
Yes
Other Medical or disability Details
*
