NDIS Online Registration Form Please complete the NDIS form below. Step 1 of 520%To assist us with your application, please complete the form below. If you need assistance completing the form, click here here to contact us.NDIS Participant DetailsTitle*MrMissMsMrsDrName* First Last Preferred NameGenderMaleFemaleOtherDate of Birth (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY NDIS No*Please provide your 9-digit NDIS number.Primary Contact No*eg. 0733445566, 0400111222 (10-digits)Secondary Contact No (Optional)Email Participant's Home Address* Building Name / Unit No. / Street No. Address Suburb State Postcode Appointment PreferencesIs this the address where consultations should be conducted?*YesNo, at alternative address.No, would like tele-therapy or online consultationNo, at Medsana Medical Clinic - Ground Floor, Building 10, Freeway Office Park, 2728 Logan Road, Eight Mile Plains, QLD 4113.Preferred Method Phone Video UnsureAlternative Appointment Address* Building Name / Unit No. / Street No. Address Suburb State Postcode Appointment requirements/preferences:(e.g. preferred time*, must have interpreter / carer, gender of therapist, etc.) *Note: As we travel all around Brisbane, your flexibility with time will help us avoid any travel-related charges or keep it to an absolute minimum.Times to AVOID for Appointments*(Considerations for school, day service, work, other regular appointments, certain people being present, etc. | eg. "Fri afternoons" or "25 June - hospital procedure".)List block-out times below. Click (+) to add more. Max. 5. Alternative ContactsAlternative Contact NameRelationship to ParticipantAlternative Contact Phone No.Alternative Contact Email Do you have an NDIS Support Coordinator?NoYesNDIS Coordinator Contact Name*NDIS Coordinator Phone No.*NDIS Coordinator Email Appointment Booking ContactPreferred contact for appointment booking* NDIS Participant Alternative Contact NDIS Support Coordinator OtherPreferred Contact's Name*Preferred Contact's Phone No.*Preferred Contact's Email Funding Management OptionFund Management Option*NDIA ManagedPlan ManagedSelf ManagedName of Plan Manager*Email Address for Invoices* NDIS Plan & GoalsStart Date*[dd/mm/yyyy] Date Format: DD slash MM slash YYYY End Date*[dd/mm/yyyy] Date Format: DD slash MM slash YYYY Please describe your NDIS goals below or upload an attachment.*Upload Your Documents Drop files here or Accepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx.Max. 5 files. Up to 10MB per file.Primary medical diagnosis relating to the participant’s disability: Select TherapiesPHYSIOTHERAPY PRODUCTSSelect the Physiotherapy services you require.PHYSIOTHERAPY Initial Assessment for Physiotherapy Needs & Report Ongoing Physiotherapy Assessment for Soft Tissue Management* Other Not Sure*Note: Soft Tissue Therapy is executed by our therapy assistants (TAs) who have had additional training in this therapy, under the guidance of our registered practitioners. See below for more information about TAs.Please describe what other Physiotherapy services you require:OCCUPATIONAL THERAPY PRODUCTSelect the OT services you require.OCCUPATIONAL THERAPY* Note that My Rehab Team does NOT do major home modifications. For a definition of major home modifications, please refer to NDIS website. Functional Capacity Assessment & Report Functional Capacity Assessment & Report to increase funding Functional Capacity Assessment & Report for SIL/SDA Application Functional Capacity Assessment & Report to ascertain Therapy Needs Functional Capacity Assessment & Report for OT Needs Assistive Technology Prescription Ongoing OT Other Not SurePlease describe what other OT services you require:SPEECH THERAPY PRODUCTSelect the OT services you require.SPEECH PATHOLOGY Initial Assessment for specific Speech Pathology Needs & Report AAC Assistive Technology Prescription Ongoing Speech Pathology Other Not SurePlease describe what other Speech Pathology services you require:PODIATRY PRODUCTSelect the OT services you require.PODIATRY Initial Assessment for specific Podiatry Needs & Report Ongoing Podiatry Orthotics Other Not SurePlease describe what other Podiatry services you require:DIETETICS PRODUCTSelect the OT services you require.DIETETICS Initial Assessment for specific Dietetics Needs & Report Nutritious Food Preparation Training Other Not SurePlease describe what other Dietetics services you require:EXERCISE PHYSIOLOGY PRODUCTSelect the OT services you require.EXERCISE PHYSIOLOGY Initial Assessment for specific Exercise Physiology Needs & Report Ongoing Exercise Physiology Other Not SureNote: GST is applicable to Exercise Physiology services.Please describe what other Exercise Physiology services you require:THERAPY ASSISTANT PRODUCTSelect the OT services you require.THERAPY ASSISTANT*Note: Therapy Assistants are indemnified by their supervising therapists so they only execute therapy programs prescribed by a registered therapist from My Rehab Team. Therapy Assistant OtherPlease describe what other Therapy Assistant services you require:Why do you think participant needs the above assessments?(E.g. improve communication, falls risk, etc.) Form Completion DetailsName Of Person Completing Form* First Last Today's Referral Date: 04/08/2020Contact No*Email* Do you need a quotation?NoYesAny other comments?eg. Work health & safety, home environment, etc.How will the service agreement (SA) be consented?*The info in this form will be used to generate a service agreement that we require to undertake therapy provision.Referring NDIS support coordinator or referrer will obtain signature from the participant / nomineeParticipant / nominee will sign SA document during the initial assessmentParticipant / nominee sign SA document electronically or provide consent via emailUnsureHow much time did you require to complete this form?Your feedback will assist us in knowing how user-friendly the form is.CommentsThis field is for validation purposes and should be left unchanged. Search for: Call 1300 469 734Fax: 07 3056 3264Make a BookingMake an AppointmentMake a ReferralNDIS ReferralNote: NDIS Referral Form is suitable all NDIS participants regardless of how their funds are managed (NDIS, Plan, or Self-managed).