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Home
Services
School Leaver Employment Supports (SLES)
Project My Turn
Application for Services
Fee Schedule
Events & More
Resources
Contact Us
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Need Help?
If you are experiencing difficulty completing this form, please call 0434 059 589 or email the Managing Director directly at services@legacylifestylesupports.com.au.
Participant Name
*
First
Last
Date of Birth
*
Phone
*
Email for general communications
*
NDIS No.
*
Plan End Date
*
Which NDIS funding lines does your plan contain? (the options you see here are the support categories we offer)
CORE - Assistance with Daily Life
CORE - Assistance with Social & Community Participation
CB - Increased Social & Community Participation
CB - Improve Daily Living Skills
Street Address
*
Address Line 1
City
State / Province / Region
Postal Code
Who lives with you?
Tell us about your family briefly. Would you like us to be aware of any family matters, cultural practices or languages other than English spoken in your home?
Do you have a diagnosed disability? If so, please state diagnosis.
Primary supports required (e.g. physical, emotional, sensory, social, safety concerns)
Food/drinks you like/dislike
Do you have any allergies/intolerances?
Areas of Interest
What goals would you like to achieve?
What would your family/parent/guardian like you to achieve?
Parent/Guardian Information (if under 18)
Mother's Name
First
Last
Mother's Address
Address Line 1
City
State / Province / Region
Postal Code
Mother's Phone
Father's Name
First
Last
Father's Address
Address Line 1
City
State / Province / Region
Father's Phone
Emergency Contact Details
In the event of a medical emergency or if we are concerned for your health and safety (ie. if you don’t answer the door for a scheduled support visit) who can we contact for you?
*
My parents
Someone else
Full Name of Emergency Contact
First
Last
Emergency Contact's Phone
Emergency Contact's Address
Address Line 1
City
State / Province / Region
Emergency Contact's Email
Emergency Contact's Relationship to Participant
Payment Details
How is your Plan managed?
Self-Managed
Plan-Managed
Agency Managed
First and Last Name of NDIS Plan Nominee
First
Last
Nominated Plan Manager (leave blank if not Plan Managed)
Email address for invoicing
*
Details of person completing this form
Details of person completing this form IF not the person with a disability or the Plan Nominee.
Name of person completing this form
First
Last
Relationship to person with disability
Phone
Email
*
Comment
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