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First Name
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Last Name
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Australia/Adelaide
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Phone
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Representative or alternative contact
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What are you hoping to achieve working with us?
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Your Diagnosis (You do not have to tell us if you don't want to.)
Do you have any communication requirements we need to be aware of?
Is there anything we should be aware of before visiting your home? (Safety concerns, pets, etc)
Do you have access to WiFi in your home?
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Do you own a smart phone or a tablet? If so, is it an Android or an Apple device?
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If you are completing this form on behalf of someone else, please write your Name, Organisation, and contact email address.
Complete if you are NDIS funded
How are your Core Supports managed?
Agency Managed
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Self Managed
How are your Capacity Building Supports managed?
Agency Managed
Plan Managed
Self Managed
How are your Capital Supports managed?
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Plan Manager Details (If Applicable)
NDIS Number
NDIS plan Start Date
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NDIS plan End Date
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