NDIS Plan Managed Intake Form

Name *

First Name

Last Name

Address *

Address where you wish for home consultations to occur.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I prefer you to contact... *

Myself as the Participant directly.

My Support Co-Ordinator

Date Of Birth *

MM

DD

YYYY

When does your current NDIS Plan end? *

MM

DD

YYYY

Are there any entry or exit points of your home that cannot be accessed or used safely (without tripping over or moving clutter out of the way)? *

Please tick one.

All inaccessible - I cannot enter or exit my home at all unless I move a significant amount of clutter.

Most inaccessible - you only have ONE entry or exit that is useable due to the clutter.

Some inaccessible - some are blocked or we would need to move some items to use them.

No - all entries and exits can be used safely, without moving anything out of the way.

Please tick any of the following that are present in your home: *

Mould

Excrement

Illegal Drugs

Weapons

Sharps

Damaged electrical wiring

Hazardous chemicals not stored in their original containers

Bed bugs

Carpet beetles

Pantry moths

Rodents

Fleas

Cockroaches

Other insect infestations

None of these are present in my home.

I understand that Orange Organising Co. is not a Registered NDIS Provider and operates as an Un-Registered Provider. Orange Organising Co. still complies with all NDIS Guidelines and the NDIS Code of Conduct. *

Yes I understand.

No - Please contact Heather on 0406501639 before proceeding.

Who has completed this form? *

I am the NDIS Participant

I am the Participant's Support Coordinator