Support Coordination Service Application

Participant's Details

Full Name

NDIS Number

NDIS Plan Date Start

NDIS Plan Date Finish

Best Contact Number

Address

Email

Age

Gender

Male

Female

Non-Binary

Not Specified

Please indicate if you are from any of the following backgrounds:

Aboriginal

Torres Strait Islander

South Sea Islander

Other

Is an interpreter required?

Yes

No

If yes- what language?

Communication support needs:

Guardian/Carer/Participant's Representatives Details

Name

Address

Best contact number

Email

Relationship to Participant

Is an interpreter required?

Yes

No

If yes- What language?

Communication support needs:

How are your NDIS funds managed?

NDIS

Self-Managed

Allied Health- Speech Pathology

Plan Manager- please specify below

Name of Plan Manager

Plan Manager phone number

Plan Manager email

Living Arrangement

Living alone

Living with family

Supported Accommodation or other (please list contact details below)

Additional living details

Is the Participant under the Office of the Public Guardian?

No

Yes (please provide a copy of the order)

Is the Participant under the NSW Trustee?

No

Yes (please provide a copy of the order)

Are there court orders?

No

Yes (please provide a copy below)

Please provide clear details for each category

Intellectual

Physical

Vision

Hearing

Mental Health

Autism

Speech

Other

Name of person completing this form

I confirm that all information listed in this application is true and correct.