Support Enquiry Form

Your Name *

Your Number *

Your Email *

Describe your relationship with the participant?

Do you have the required information of the participant available? Including birthdate, NDIS info & Representative details. *

YesNo

The Participant and/or the representatives are informed about this referral and have provided consent. *

Please provide details *

Participant Details

First Name *

Last Name *

Date of Birth *

NDIS Number *

Age

The participant does not have contact info

Email *

Phone Number *

Please provide details *

Street address *

City *

State *

Postcode *

Gender

MaleFemaleNon-BinaryOther

Pronouns

What supports are required? *

Support CoordinationIn Home SupportCommunity Participation

You can select more than one support service if required.

Do you have an Authorised Representative? *

YesNo

Do you have a Current Support Coordinator *

YesNo

Do they have an Authorised Representative? *

YesNo

Do they have a current Support Coordinator? *

YesNo

Do you have specific preferences related to communication devices, contact methods, cultural or religious considerations, easy-read documents, language preferences (written and spoken), or any other requirements? *

YesNo

Do they have specific preferences related to communication devices, contact methods, cultural or religious considerations, easy-read documents, language preferences (written and spoken), or any other requirements? *

YesNo

Is an interpreter required? *

YesNo

Communication Details *

Authorised Representative details

Please provide datails for the authorised representative.

First Name *

Last Name *

Phone Number *

Email *

What is the relationship with the Participant? *

ParentLegal GuardianPlan Nominee

Support Coordinator Details

Please provide details for the current support coordinator

First Name *

Last Name

Emial *

Phone *

Organisation *

Support Services

What types of support do you need in your daily life, for example do you need support at home, work, school, in the community?

Do you need assistance with transportation?

YesNo

Do you have a preference to support worker

No PreferenceMale Female

Support Coordination

I understad and I acknowledge that there can be a Conflict of Interest where starfish provides both Support Coordination and Support Services for myself *

I understad and I acknowledge that there can be a Conflict of Interest where starfish provides both Support Coordination and Support Services for the participant. *

Is this your first NDIS Plan? *

YesNo

Is this the Participants first NDIS Plan? *

YesNo

What would you like assistance with?

Please upload a copy of your NDIS Plan

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This is not mandatory but is helpful for our Support Coordinators to understand your goals, support needs and funding allocated.

Please upload a copy of their NDIS Plan

Browse

This is not mandatory but is helpful for our Support Coordinators to understand the goal, support needs and funding allocated for the participant.

By submitting this form, you agree to us collecting and storing personal information for the purpose of establishing and providing NDIS Supports.

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