Get to Know You - one on one services

In preparation for our next program, we’d like to get to know you a little better.

Please complete the following form so we can cater for your individual needs at the up coming event.

Participant name:

First Last

Please outline the NDIS goals and the reason for referral to this service:

Will a report/summary letter be required for this support?

Yes

Please note this is in addition to the quoted hours in the Schedule of Supports.

Participant's primary diagnosis:

Are there any other health, learning or behavioural considerations to be aware of to assist with support the participant?

Yes

If yes, please provide details:

Does the participant have any triggers that need to be considered when providing supports?

Please list any allied health supports the participant is engaged in:

Who is the primary contact for appointments and service discussions?

First name Surname

Mobile number:

Email:

Enter Email Confirm Email

Relationship to participant:

Is this person the primary emergency contact for the day?

Yes

Emergency contact:

First name Surname

Mobile number:

Email:

Enter Email Confirm Email

Support environment:

Additional information:

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