Full name of NDIS Participant (Required)
Date of Birth
Gender
Address, including state and postcode
Participant's phone number (phone number of nominee/primary contact can be completed further down this form)
Email address (this address will receive a copy of this completed registration form and signed service agreement - Required)
NDIS number
Plan start date if known
Plan end date if known
If you have a copy of your NDIS plan, please attach it below
Please select your preferred invoice approval method: Auto approve (We will process/pay all invoices without contacting you first)Email approval (We will email you a copy of each invoice before making payment)SMS approval (We will text you a summary of each invoice before making payment)
If you have a NDIS nominee, please list their contact details below
Nominee name
Nominee phone number
Nominee email address
If you have a Support Coordinator (SC), please list their contact details below
Support coordinator name
Support coordinator phone number
Support coordinator email address
You may have listed a few different people above. Who should we first contact if we need to get in touch? This person will receive all general communication from us, including the participant's login details to our app
What is this person's relationship to the Participant (parent, sibling, friend etc)?
What is this person's preferred method of contact? TelephoneEmail
How did you hear about us? Google searchNDIS websiteNDIS planner/LACSocial mediaSupport CoordinatorFriend/FamilyPeace of Mind FoundationOther
Please let us know any other important information about you or your disability, that can help us to best service your needs
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