Participant Enquiry - Interchange Illawarra

New Participant Enquiry Form

Thank you for contacting Interchange Illawarra. It would be appreciated if you could complete this New Participant Enquiry Form so we can begin to understand a little bit about you and how we may be able to support you. By completing this form you agree to Interchange collecting and holding personal information about you, including information in your NDIS Plan. If you would like more information about how we collect, store and use your information please email info@interchangeillawarra.org.

Initial Participant Enquiry 2023

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?

Search engine eg. Google

Social Media eg. Facebook

Referral

Word of mouth

Marketing event

Other

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

Gender:

Male

Female

Other

Your/Participant's disability:

Acquired Brain Injury

Autism Spectrum Disorder

Intellectual

Neurological

Physical

Psychiatric

Sensory

Specific Learning

Other

If other for disability, please provide further details:

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 short term accommodation options in Wollongong and Lake Illawarra with group or 1:1 support options)

Short Holidays (Short Holidays are offered to suitable participants in small groups to a wide variety of locations within Australia)

Support Coordination (Support Coordination identifies goals and aspirations and coordinates access to the services and supports you require)

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)

Saturplay (Saturplay is a customised support environment run on Saturdays for children 4 to 12 years of age with Autism or challenging behaviours)

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.