Application for Services -

Application for Services

The contents of this application form will be used only by Legacy Lifestyle Support staff. It will provide a guide for us to understand how we can begin working with you. If you have difficulty completing this form, please complete the HELP section at the bottom so our team can make contact with you to provide assistance.

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

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 *

Name