Participant Enquiry

Thank you for contacting Interchange Illawarra. It would be appreciated if you could complete this Participant Enquiry 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. 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?

Date of Enquiry

Your/Participant's Full Name

Phone Number

Postcode

Date of Birth

Gender

Male

Female

Other

Do you have an NDIS Plan?

Yes

If other for disability, please provide further details

Please tell us what services you require or are interested in

If you selected other for Services, please provide further details

Please add any further information or questions you may have

Prefer to speak to us in person? Call in to our office for a chat