Request for support services

Referral details

Who is completing this form*

Relationship to client*

Phone*

Email*

Client information

First name*

Last name*

Gender

Female

Male

Non-binary

Date of birth

Postcode*

Phone (mobile or home)*

Email*

Do you or your family require an interpreter?*

Yes

If yes, please describe your interpreter needs*

Support Coordinator (name, phone number & email)*

Funding source*

NDIS

TAC

Self-funded

Other

If other, please provide details of other funding source*

Primary contacts

First name*

Last name*

Relationship to client requesting service*

Phone (mobile or home)*

Email*

Current living arrangements

Do you currently live with?*

Family members

With others

On your own

If you selected other, please describe your current living arrangement*

Behaviour and support needs

Please describe your disability*

Do you have social or behaviour needs?*

Yes

Do you have a behaviour support plan?*

Please upload a copy of the behaviour support plan at the end of this form.

Yes

Timetable of supports requested

Please provide detail of the kinds of support you require each day. For example 24 x 7 care, community access, morning support only to assist with personal care.

What suburb is the support needs required?*

Monday details of support*

Tuesday details of support*

Wednesday details of support*

Thursday details of support*

Friday details of support*

Saturday details of support*

Sunday details of support*

Transition information

Are you making a transition from a current service provider to eQuality Support service?*

Yes

If yes, please provide details of the transition*

Referral source

Other*

Privacy Statement*

The information collected on this form will not be disclosed to any outside individual or organisation without your consent or as required by law. All information collected will be kept private and stored securely. As part of our compliance and regulatory requirements, it is necessary for eQuality Support to provide information to DHHS, NDIS, and TAC on a regular basis. The information assists in ensuring appropriate funding and quality of service. Please indicate your understanding of this by ticking the box below.

Document uploads

Please upload any documents you feel support your request for service

eg behaviour support plans, recommendation letters, allied health letters

Drag and drop files here or

Send me a copy of my responses

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