NDIS Online Registration Form

Note: We accept referrals for clients above the age of 7 years old if they have a neurological diagnosis. For Speech Pathology for young clients, we only have the capacity to conduct at our partner clinic – Medsana, rather than visiting at home. We are unable to do Positive Behavioural Support Plans.

Please complete the NDIS form below.

Step 1 of 5

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 Details
Title*
Name*
First Last
Preferred Name
Gender
Date of Birth (dd/mm/yyyy)*
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

Please provide an email address so we can send our easy-read NDIS guide (requirement for all NDIS clients) - if hardcopy is preferred, let us know e.g. "Hardcopy please"
Participant's Home Address*
Building Name / Unit No. / Street No. Address Suburb State Postcode
Appointment Preferences
Is this the address where consultations should be conducted?*
- Yes for in-person appointments
- No, at alternative address.
- I am ok with tele-therapy (via phone) or online consultation (via Internet)
- In-person at Medsana Medical Clinic - Ground Floor, Building 10, Freeway Office Park, 2728 Logan Rd, Eight Mile Plains
Preferred Method
- Phone
- Video
- Unsure
Alternative 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.

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Funding Management Option
Fund Management Option*
- NDIA Managed
- Plan Managed
- Self Managed
Name of Plan Manager*
Email Address for Invoices*
NDIS Plan & Goals
Start Date*
[dd/mm/yyyy]
DD slash MM slash YYYY
End Date*
[dd/mm/yyyy] Please check end date is correct (especially month and year) to help us forecast plan reviews
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. file size: 10 MB, Max. files: 5.
Max. 5 files. Up to 10MB per file.
NDIS access diagnosis(es) relating to the participant’s disability:

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Form Completion Details
Name Of Person Completing Form*
First Last
Today's Referral Date: 17/01/2022
Contact No*
Email*
Do you need a quotation?
- No
- Yes
Any other comments?
eg. Parking availability/directions, 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.
- Participant / nominee will sign SA document during the initial assessment
- Participant / nominee sign SA document electronically or provide consent via email
- Referring NDIS support coordinator or referrer will obtain signature from the participant / nominee
- Unsure
Is Public Guardian consent required?
- Yes
- No
We will expedite the initial Service Agreement if so, as it can take time to obtain Guardian consent. We cannot proceed with 1st appt without consent.
Comments
This field is for validation purposes and should be left unchanged.

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Call 1300 469 734

Fax: 07 3056 3264

Make a Booking

Refer Non-NDIS Client

Refer NDIS Client

Note: NDIS Referral Form is suitable all NDIS participants regardless of how their funds are managed (NDIS, Plan, or Self-managed).

NDIS Online Registration Form

Step 1 of 5

NDIS Participant Details

Appointment Preferences

Alternative Contacts (for appt booking)

Appointment Booking Contact

Funding Management Option

NDIS Plan & Goals

Select Therapies

Form Completion Details

Call 1300 469 734

Make a Booking

List block-out times below. Click (+) to add more. Max. 5.