NDIS Participant and Plan Details

If you require assistance completing this form please call: (07) 3088 2323.

Please fill in the below form and a member of our team will be in contact to book your initial appointment.

Email Address of Person Submitting the Form (Optional)

Participant Details

Title *

Gender *

First Name *

Last Name *

Date of Birth *

Mobile Number

Participant Email Address

Participant's Address *

Street address *Street address line 2

City *

State *

Postcode *

Next of Kin or Emergency Contact Details

Name of Participants Next of Kin *

Next of Kin's Relationship to Participant *

Next of Kin Phone Number *

Next of Kin Email Address

Plan Information

Services Required *

DietitianExercise PhysiologyDiabetes EducatorTherapy Assistant (Allied Health Assistant)

Benefits of a Therapy Assistant -

Increased frequency of sessions which allows more time to dedicate to understanding your circumstances to help our team provide best care.
Implementing the use of therapy assistants can increase service frequency and support to help get the most out of your NDIS funding associated with allied health support.
Implement Therapy Programs by spending adequate time with participants.
Report writing and up to date communication with the allied health professional so any adjustments that are needed can be made and implemented.

Is participants plan on the new NDIS PACE system?

YesNo

If yes, please list Healthy Lifestyles Australia as a MyProvider

Participant NDIS Number *

Plan Start Date *

Plan Finish Date *

Funding Type *

Assistance with Daily Life (Category 1)Improved Health & Wellbeing (Category 12)Improved Daily Living (Category 15)

How is the plan managed? *

NDIA ManagedPlan ManagedSelf Managed

NOTE: If NDIA managed, please enter participant information in below fields.

Who is the contact person for invoicing purposes?

First Name *

Last Name *

Contact Person Email Address

Phone *

Email address for sending invoice to for payment if different from delegate *

Who is the Support Coordinator?

First Name

Last Name

Email

Phone

Who is the contact person for booking and confirming appointments?

First Name *

Last Name *

Email *

Phone *

Who should we send Service Agreements to for Signing?

First Name

Last Name

Email *

Phone *

Who should we send Service Agreements to once signed?

First Name

Last Name

Email *

Phone *

Who should we send Clinical Reports to?

First Name

Last Name

Email *

Phone *

Are there any other stakeholders/ carers/ support workers/ nurses that you consent our practitioners to liaise with regarding the participant? If so, please provide their contact details

Clinical Information

Are home visits required? *

Yes No

Most appointments are booked in clinic, however Offsite/Home visits may be available. Please indicate if this is required.

NOTE: Travel time and expenses are charged in line with NDIS guidelines

Are interpreter/Auslan services required? *

YesNo

Are any other health professionals using the funding? *If so, please provide details and the amount of funding allocated to Healthy Lifestyles Australia.

Participants primary condition / disability / impairment/s approved by the NDIA *

Is there any medical history about the participant that you can share with us that would assist the practitioner in their consult?

What Medical Centre does the participant attend for GP appointments?

Any additional information EG: services required, availability, frequency

NDIS Plan

Participants NDIS Plan Goals (Otherwise upload plan below)

Please upload a copy of your NDIS plan or Essential Sections as Outlined Below

Browse

Multiple files can be uploaded but we do prefer a single pdf document.

Please note it is your decision how much of your plan you share with us, however the sections we request that are most suitable for delivering care include the following. Please note we ensure your provided information remains confidential:

Cover Page
Including start & end dates and the participants NDIS number

Goals Section
Including participants goals

Funding Section
Specifically funding relating to the Dietitian, Diabetes Educator, Allied Health Assistant and/or Exercise Physiologist.

NOTE: funding will be either Improved Health and Wellbeing, Improved Daily Living, or Assistance with Daily Life (Diabetes Education is only available under Improved Daily Living and Assistance with Daily Life)

PLEASE NOTE
If requested funding is not available at time of billing, the participant will be responsible for any payments for services received but not covered by their NDIS plan.

Service Agreement for Initial or Ongoing Appointments

By signing below, you acknowledge and agree to receive either an initial or ongoing consultations with Healthy Lifestyles Australia as part of the National Disability Insurance Scheme (NDIS) participant process.

Please note we have a 2 business day cancellation or failure to attend policy as per NDIS guidelines (full fee payable as per billing preferences). You acknolwedge this by signing below.

Please select which type of service agreement you require: *

Initial Service Agreement (By selecting this you are agreeing to the initial 2 Hours of services and any Travel if required. This option is best if you do not have a budget for us to work with and would like a recommended service breakdown following the initial appointment), OROngoing Service Agreement (This option is best if you have a budget you would like us to work with. When selecting this option please provide the budget in the below box so we can best plan ongoing services with you)

If you have selected "Ongoing Service Agreement" provide a budget for the services you have requested: *

I have read and agree to Healthy Lifestyles Australia's standard service agreement terms and conditions: *

Yes

Standard Service Agreement Terms and Conditions

Signature of Participant / Legal Guardian / Authorised Signing Officer *

Draw signature|Type signatureClear

Date *

*If participant is represented by the Office of the Public Guardian (OPG), please type as text in signature above "OPG Approval Needed".

Name of Person Signing *

Please click Submit below and a member of our team will contact you to book in your initial consultation. After the initial consultation, the allied health professional will work with you to determine the most appropriate service delivery frequency.

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