Ready To Get Started? I am completing this for *SelectMyself as a ParticipantSomeone i am referring to C. Home and Community CareFirst NameLast NameDate of BirthGender *SlectMaleFemalePrefer not to SayHome Address *Participant Phone Number *Participant Email Address *Participant NDIS NumberDoes The Participant Have A Legal Guardian / Nominee? *YesNoCultural DetailsParticipant Country Of BirthDoes The Participant Require An Interpreter? *SelectYesNoRelevant Culture Or Religious Considerations(If Any)?Does The Listed Participant Identify As An Aboriginal Or Torres Strait Islander? *SelectYesNoServices RequestType Of Primary Service Required: *SelectAccommodation and Tenancy ServicesAssit prod pers care/ Safety ServicesLife Stage and Transition SupportPersonal Activities SupportTransport and Travel AssistanceHome Modification ServicesCommunity Nursing CareDaily Tasks and Shared LivingInnovative Community ParticipationDevelopment of Life SkillsHousehold TasksParticipate CommunityPlan ManagementTherapeutic SupportSpecialized Disability AccommodationGroup Centre ActivitiesNumber Of Hours Requested For Service: *Type Of Secondary Service Required:SelectAccommodation and Tenancy ServicesAssit prod pers care/ Safety ServicesLife Stage and Transition SupportPersonal Activities SupportTransport and Travel AssistanceHome Modification ServicesCommunity Nursing CareDaily Tasks and Shared LivingInnovative Community ParticipationDevelopment of Life SkillsHousehold TasksParticipate CommunityPlan ManagementTherapeutic SupportSpecialized Disability AccommodationGroup Centre ActivitiesAdditional Service Required:SelectAccommodation and Tenancy ServicesAssit prod pers care/ Safety ServicesLife Stage and Transition SupportPersonal Activities SupportTransport and Travel AssistanceHome Modification ServicesCommunity Nursing CareDaily Tasks and Shared LivingInnovative Community ParticipationDevelopment of Life SkillsHousehold TasksParticipate CommunityPlan ManagementTherapeutic SupportSpecialized Disability AccommodationGroup Centre ActivitiesParticipant's Relevant Conditions / Disability (Please List):Extra Information That May Assist With Preparation For Initial Appointment:Special Assessments Or Therapies Required:Notes For Practitioners (Additional Relevant Details): Booking Details Preferred Consultation Type(s): *In ClinicIn Home ServiceTelehealthCommunityWho Should We Contact To Make An Appointment? *SelectParticipant / NomineeSupport CoordinatorOtherNotes For Reception Staff (If Applicable):HTML NDIS Information Participant’s NDIS Plan Type *SelectNDIA ManagedPlan ManagedSelf / Nominee ManagedPlease Upload NDIS Plan And Relevant Details *Drag and Drop (or) Choose FilesSubmit
