Participant Details Given Name Surname Date of Birth Gender Preferred Pronouns NDIS Number Plan Start Date Plan End Date Participant Address This Address isOwn/Family HomeSDA/Supported AccommodationRACOther Phone Email Referrer Details Referrer Name Relation to participantSelfParentNext of KinSupport CoordinatorAccommodation ServiceLegal Guardian/POAAdvocateOther Organisation Phone Email Guardian/Nominee/Person Responsible Guardian/Nominee/Person Responsible Name Relation to participantSelfParentNext of KinSupport CoordinatorAccommodation ServiceLegal Guardian/POAAdvocateOther Phone Email Communication Who is the best person to contact How did you hear about us?—Please choose an option—Current EmployeeWord of MouthInternetSocial MediaReferred by other professional/servicePromotion at expo/eventParticipant previously accessed serviceOther Is an interpreter requiredYesNo If Yes, which language/dialect? This Address isOwn/Family HomeSDA/Supported AccommodationRACOther Aboriginal and Torres Strait Islander IdentityNeither Aboriginal nor Torres Strait IslanderAboriginalTorres Strait IslanderBoth Aboriginal & Torres Strait Islander GP Name/Contact Details Disability Details Disability/DiagnosesAutism Spectrum DisorderSpinal Cord InjuryHearingIntellectual/Dev. DelaySpina BifidaVisionAcquired Brain InjuryOther PhysicalNon-verbalDown SyndromeCerebral PalsyDementiaMental HealthMS or other NeurodegenerativeOther NDIS Payment Details Disability/DiagnosesPlan ManagerNDIS Agency ManagedSelf-Managed Invoice Details for Self and Plan Managed Name Organisation (if applicable) Email Phone Service Required Behavioural Intervention & ManagementPsychotherapy/CounsellingDevelopmental EducationRespite/STAMTASupported Independent LivingSupport Coordination/PRCAssistance with Personal Daily ActivitiesCommunity ParticipationSpecialised Disability Accommodation (SDA) Risk Assessment; please specify level of risk (Low/Medium/High) Physical Aggression Verbal Aggression Substance Abuse Accommodation issues Other; please specify Participant's Strengths, Concerns, and NDIS Goals ConsentAgree I acknowledge and consent to Luminous Care collecting and securely storing the information I have provided. I understand this information will be safely and securely stored in accordance with the Australian Privacy Principles, and Luminous Care's Privacy Policy, available at https://luminouscare.com.au Document
