Participant Enquiry - Interchange Illawarra

Please indicate your consent below. If your enquiry is on behalf of another person, you will still need to get their consent to collect their personal information including NDIS Plan Details.

I consent to the collection and storing of my information by Interchange Illawarra.

I authorise my representative named on this form to enquire on my behalf and give consent to the collection and storing of my information by Interchange Illawarra.

How did you hear about us?

Participant's Full Name *

Name of person completing form (if not the Participant)

Relationship to Participant e.g. Carer, Support Coordinator

Phone Number

Contact Email Address

Postcode

Age of Participant

Do you have an NDIS Plan?

Yes

If yes, do you have core supports in your NDIS Plan?

Yes

Gender:

Male

Female

Other

Your/Participant's disability:

If other for disability, please provide further details:

Please describe the participant/person’s needs and interests:

Please tell us what services you require or are interested in:

1:1 Support Community Access (One to one support provided to assist you pursue personal interests or hobbies)

1:1 Support Daily Living Skills (One to one support provided to help you reach your daily living skills goals)

1:1 Support Personal Care (One to one personal care support provided in your home)

Short Term Accommodation (We offer local group and individual Short Term Accommodation for suitable participants 18 years and over)

Social Support Groups (Social Support groups offer a wide range of options including day trips, dinners out, craft, cooking and outings like bowling or the cinema)

MyTime (MyTime is for parents and carers of a child (aged 0-16 years) with a disability, chronic medical condition or other additional needs including developmental delay)

Other (Any other requests not covered by the options above - please specify below)

If you selected other for Services, please provide further details:

Please add any further information or questions you may have:

If you are human, leave this field blank.

New Participant Enquiry Form

Prefer to speak to us in person? Call in to our office for a chat or phone 4227 1079.