NDIS Service Request LIVE v1.0.2 NDIS Onboarding Form 0% Complete1 of 3 NDIS Service Request Form Are you submitting this form for yourself or on behalf of another? Myself On behalf of another Submitter Name * First Last Name * Last Relationship with the Client * ParentSpouseGuardianOther Family MemberService ProviderFriendEmployerPlan Nominee Are you a NDIS Nominee and/or Legal Guardian for the participant? * Yes No Please note, as you are not the NDIS Nominee and/or Legal Guardian for this participant, after submitting this service request a member of our team will contact the participant and/or their NDIS Nominee / Legal Guardian to affirm the service request. Please provide a copy of the participant's current Guardianship order or confirmation as Plan Nominee in the file dropdown at the bottom of this page. Participant's Name * First Last Name * Last What is the participant's NDIS Number? * All NDIS numbers begin with '43' and are 9 digits long What is the participant's date of birth? * What is the participant's phone number? (inclusive of area code if applicable) * What NDIS services is the participant interested in accessing? * Plan Management Support Coordination Specialist Support Coordination Psychosocial Recovery Coach Individual Support Activity Groups Therapeutic Groups Counselling One-to-One Art Therapy Is the participant a current NDIS participant with Skylight Mental Health? * Yes No What is the participant's email address? * Enter Email Confirm What is the participant's email address? * Confirm Email What the participant's gender? * MaleFemaleIndeterminateIntersexTransgenderFemale - TransgenderMale - TransgenderNon - BinaryI would prefer not to sayOther What the participant's gender? What is the participant's primary disability? * ABIAutism Spectrum DisorderDevelopmental delayIntellectual disabilityNeurological disabilityPhysical disabilitySensory disabilityPsychosocialI would prefer not to sayOther What is the participant's primary disability? Participant's Street * Participant's Suburb * Participant's State * ACTJBTNSWNTQLDSATASVICWA Participant's Postal Code * What region does the participant reside in? Central MetroNorthern MetroSouthern MetroAPYEyreMurray MalleeLimestoneFleurieu How did you hear about us? * Google or Online adsLocal Area CoordinatorWord of mouthSocial mediaPoster/BrochureReferring organisationOther How did you hear about us? What is the participant's preferred communication method? * Phone Email Mail Is the participant currently under a guardianship or supervision order? * Yes No Please provide us a copy of the participant's guardian or supervision order in the below file upload section. Does the participant have a NDIS Plan Manager? * Yes No I have funding for a Plan Manager but have not selected one yet Who is the participant's current Plan Manager? * What is the participant's Plan Manager's email address? Does the participant have a NDIS Support Coordinator and/or Psychosocial Recovery Coach? * Yes No I have funding for a SC / PRC but have not selected one yet Who is the participant's current Support Coordinator? * What is the participant's Support Coordinator's email address? Does the participant have a Carer? * Yes No Carer's name * Carer's Phone Number * Carer's Email * Does the participant have an Emergency Contact? * Yes No In the event the participant does not have an Emergency Contact, we will notify Mental Health Triage 13 14 65 if we have serious concerns about their wellbeing. Who is the participant's preferred Emergency Contact? * Emergency Contact Phone Number * Emergency Contact Email Please provide a copy of the participant's current NDIS plan and/or any other relevant files Drop a file here or click to upload Choose File Maximum file size: 33.55MB If you are human, leave this field blank. Next
