Support Coordination Intake Form

Welcome to Aspect Support Coordination

Once we have received this completed form, our Support Coordination team will be in contact within 7 business days to assess your NDIS plan and prepare your service agreement in order to provide services.

If you any questions regarding this form, please call us on: 1800 277 328 or email: customerservice@aspect.org.au

Participant Details - the person who will receive the supports

Support Coordination participant eligibility requirements are available HERE

Participant First Name *

Participant Last Name *

Email *

Mobile *

Does the participant have an NDIS plan ? *

YesNo

Does the participant's plan include funding for Support Coordination? *

YesNo

What level of Support Coordination Funding does the plan include? *

Level 1 - Support ConnectionLevel 2 - Coordination of SupportsLevel 3 - Specialist Support CoordinationUnsure

How many funded hours are available for Support Coordination in the current plan period? *

Have you ever accessed Support Coordination before? *

YesNo

Please provide details *

We're sorry Aspect is only able to provide Support Coordination to participants with an NDIS plan.

The plan must include specific funding for Support Coordination, Level 2 or Level 3.

Please contact the NDIA at "Access the NDIS" to apply for a plan.

Alternatively, you can speak to your NDIS planner to request changes to your current plan.

If you have further questions, please call 1800 277 328 or email: customerservice@aspect.org.au

Thank you

Participant details (cont'd)

Date of Birth *

Gender *

FemaleMaleTheyOther

Please indicate preferred pronouns

If other, please indicate gender *

Street Address Line 1 *

Street Address Line 2

City *

State *

Post Code *

Do you identify as Aboriginal or Torres Strait Islander? *

YesNo

Country of Birth *

Please specify *

NDIS Details

Information about our current Support Coordination fees is available HERE

NDIS Client Number: *

NDIS Plan Start Date *

NDIS Plan Expiry Date *

How is your plan managed? *

Self ManagedPlan ManagedAgency Managed

Please provide the name of the provider *

How would you like Support CoordInation Services delivered? *

Face-to-faceTelehealthEither

Please note face-to-face Support Coordination is only available in Sydney & Newcastle NSW, & Melbourne VIC.

If you do not live in these areas, or cannot travel to these locations, please select TELEHEALTH.

Enquirer Details

Who is completing this form? *

I am the participantI am enquiring on behalf of the participant

Enquirer First Name *

Enquirer Last Name *

Enquirer email *

Enquirer mobile number *

Relationship *

Please specify relationship to participant *

Who is the best person to contact? *

ParticipantEnquirer (the person completing this form)Other (please specify below)

Contact's first name *

Contact's last name *

Contact's email *

Contact's mobile number *

What is the contact's relationship to the participant? *

Participant Living Arrangements

Living Arrangements *

If other, please specify *

What languages are spoken at home? *

Is an interpreter required? *

YesNo

Who makes the decisions for this participant? *

I make my own decisionsSomeone helps the participantThere is a Legal Guardian in place

Decision Maker Full Name *

Decision Maker Email *

Decision Maker Contact Number *

Are there any custody arrangements or parenting plans in place that we need to be aware of? *

YesNo

Please provide details *

Is there anything else you think we should know?

By ticking this, I confirm that all information supplied at the time of completion is accurate *

Save and Complete Later