Skip to content

Community Health
Workplace Health
NDIS

ONLINE REFERRALS BOOK ONLINE CALL US

Search for:

Allied Services
Who We Treat
Services
Latest Research
About Us

Search for:

Allied Services
Who We Treat
Services
Latest Research
About Us

Allied Services
Who We Treat
Services
Latest Research
About Us

Loading...

NDIS Service Request Form

Home
Service Request Forms
NDIS Service Request Form

NDIS Service Request FormAnton Mastrullo2021-10-07T20:23:31+10:30

Complete the form below. If you need any assistance Call Central Reception between 9:00 am and 5:00pm on (08) 8244 0450.

Participant Details

Name *

First

Last

Email *

Contact Number *

Date of Birth *

dd/mm/yyy

Gender *

Male
Female
Non-binary
Prefer not to say

Address *

Address Line 1

City

State / Province / Region

Postal Code

Living Arrangements

Alone
Family/Partner
Supported Accommodation
Other

Living Arrangements if 'Other'

Preferred Language

Cultural Preferences

E.g. Female Practitioner only.

Translator/interpreter or communication aids required?

Please include all necessary include details.

Who is the Primary Contact for an appointment?

Primary Contact *

Participant
Family Member
Support Coordinator
Advocate
Other

Primary Contact if required

Primary Contact's role if 'Other'

Please provide the Primary Contact's details below.

Primary Contact's Name

First

Last

Primary Contact's Email

Primary Contact's Contact Number

Is the Primary Contact the Advocate? *

Yes
No

Please provide the Advocates Name and Email and/or Contact Number.

Name

First

Last

Email

Contact Number

NDIS Details

NDIS Plan Number *

Start Date *

dd/mm/yyy

End Date *

dd/mm/yyy

How is your plan managed? *

NDIA
Plan Managed
Self Managed

Name of Organisation *

Organisation Email *

Organisation Contact Number *

Alternative Email

Provide an alternative email, if applicable. Personal details are as above.

Category of funding *

Improved daily living
Improved health and wellbeing

Referrer Details

Referring Yourself?

If you are referring yourself please check here and move to the next question.

Name of Organisation

Name

First

Last

Email

Contact Number

State

Postcode

Referrer's Role

Support Coordinator
Case Manager
Family Member
Local Area Coordinator
Other

Referrer's Role if required

Referrer's Role if 'Other'

Primary Disability / Health Background

Please provide the primary physical disability or psychological disability: *

E.g. Intellectual Disability, Cerebral Palsy, Multiple Sclerosis.

Services

Select Services *

Exercise Physiology
Physiotherapy
Dietetics

You can select more than one option

Preferred Delivery of Services *

In Clinic
Home Visit
Telehealth

You can select more than one option

Home Visit - Safety

In order to proceed with your request ALL questions regarding Home Visits must be answered.

If Yes provide details - type in the box to answer.

Is anyone at your / the client’s property, known to be aggressive or violent? *

Yes
No
Don't Know

Aggressive or Violent details *

Details if Yes

Does anyone at your/the clients property have a criminal history? *

Yes
No
Don't Know

Criminal History? *

Details if Yes

Does the client have a positive behavioural support plan in place? *

Yes
No
Don't Know

If Yes - please attach a copy of the PBS.

Is there a history of drugs or alcohol misuse at the property? *

Yes
No
Don't Know

Drugs or Alcohol? *

Details if Yes

Are you aware of any firearms being stored at the property? *

Yes
No
Don't Know

Firearms? *

Details if Yes

Are you aware of any occupant having an infectious disease? (i.e. Chicken Pox / Covid / Gastro, etc.) *

Yes
No
Don't Know

Infectious Diseases? *

Details if Yes

Do you have any pets at your premises? *

Yes
No
Don't Know

Pets? *

Details if Yes

Are there any other factors we should be aware of? *

Yes
No
Don't Know

Any other factors? *

Details if Yes

Complete this NDIS Service Request Form

Type name to sign and submit *

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Upload any relevant documentation.

Contact AEP

Phone: (08) 8244 0450

Fax: (08) 8244 0451

Email: [email protected]

Adelaide Exercise Physiology (AEP)

We are a South Australian owned group of allied health professionals, who are passionate about helping people in their local community.

Find us

Search site

Search for:

Page load link

Go to Top