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Participants Name

Address

Date of Birth

Participant NDIS #

NDIS Plan Dates

Contact Person

Phone

Email

Diagnosis

Goals/ Reason for Referral

Service Request Service Request SIL Home Care Community Nurse Cleaner Respite

Duration of Placement Duration of Placement Short term Long Term

Referrers Name

Level of Need Level of Need High Low

Organisation

Contact Phone

Email

Location of Initial Visit

How Will the Participants Support Services Be Paid?* How Will the Participants Support Services Be Paid?* NDIS will pay my support provider (in this case Simplicity Care ☐) directly for these supports. (Agency-managed.) NDIS will pay me directly for these supports. I will then pay the invoice that Simplicity Care sends to me, within 7 days. (Self-managed.) NDIS will pay my plan management agency directly for these supports. SC should send invoices to my plan management agency and they will then pay SC. (Plan-managed.)

Support Area Support Area Improved Daily Living Finding & Keeping a Job Community Access Personal Care & Grooming Household/ Domestic assistance Improved Health & Wellbeing

How did you hear about us How did you hear about us Email Facebook Google NDIS planner Others

Is the Participant accessing Services from another Provider? Is the Participant accessing Services from another Provider? Yes No

Amount of Funding to be used