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Participant Enquiry Form
Date of 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 email@example.com. 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
Your/Participant's Full Name
Name of Person Making Enquiry, if not Participant
Relationship to Participant
Preferred Contact Person's Name
Preferred Contact Person's Phone Number
Preferred Contact Person's Email Address
Your/Participant's Date of Birth
Please tell us about your/the Participant's Disability(s)
Do you/the Participant have a Carer?
If you/the Participant has a Carer, what is their name?
NDIS Plan Start Date
NDIS Plan End Date
What is your reason for contacting Interchange Illawarra?
Information about who we are and what services we offer
Support Coordination enquiry
Further information on how we can support you with your personal goals
Further information on Individual Support/Short Term Accommodation
Further Information on Social Support (Group Activities)
Quote for service
Please describe the type of support you/the Participant needs.
Please choose from the dropdown what your/the Participant's Living Arrangement is
Lives with Carer/Family
Lives with Others
What is your/the Participant's Primary Language?
Do you/the Participant require an Interpreter?
Do you/the Participant have any Communication Impairments?
Further information about your/the Participant's Communication Impairments (if applicable)
Do you/the Participant require Mobility Aids?
What type of Mobility Aid do you/the Participant require?
Uses an electric wheelchair
Uses a manual wheelchair
Does not use a wheelchair or other mobility aid
Uses another mobility aid (walking frame, guide dog, other)
Do you/the Participant have a Seizure Plan?
Do you the participant have a Nutrition/Swallowing Plan?
Do you/the Participant require Special Nursing? (eg. Peg Feeding)
If Special Nursing required, please provide details
Do you/the Participant have any Medical Conditions?
If you/the Participant have any Medical Conditions? Please list them below
Do you/the Participant require support with Self Care/Toileting?
If you do require support with Self Care/Toileting, please provide further details
Do you/the Participant require support with eating and drinking?
If you do require support with Eating and Drinking, please provide further details
Do you have other Support Needs that we have not mentioned above? If so, please provide details.
Do you/the Participant have a Behaviour Plan/Strategy?
If you are human, leave this field blank.
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