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Heart of lorrimar lodge
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First name
(required)
Last name
(required)
Email
(required)
Phone number
(required)
Date of birth:
(required)
NDIS Number (if applicable)
Address
Guardian/Representative (if applicable)
Relationship to Participant
Phone number
Email
Are you NDIS funded?
Yes
No
Plan type (if yes):
Self-managed
Plan-managed
NDIA-managed
Plan Manager and Support Coordinator (if applicable)
Primary diagnosis/support needs
Communication needs or preferences
Sensory considerations
Behavioural considerations
What services are you interested in?
Animal Therapy
Respite Activites
Individual Support
What are your goals for support?
Medical conditions we should be aware of?
Allergies?
Medications (if relevant)
Is there anything that may impact safety during activities?
Date you wish to commence
YYYY-MM-DD
Emergency Contact – Name
Emergency Contact – Phone number
Emergency Contact – Email
Consent
I confirm that the information provided is accurate to the best of my knowledge
I consent to Heart of Lorrimar Lodge collecting and storing this information for the purpose of providing services
I understand that services will be tailored based on the information provided
I consent to emergency medical assistance being sought if required
I consent to photos/videos being taken for documentation/marketing purposes
By submitting this form, you consent to Heart of Lorrimar Lodge collecting and storing your information for the purpose of service delivery, planning, and communication. All information is handled in accordance with privacy and confidentiality requirements.
Name – Signature (typed)
(required)
Date Submitted
(required)
YYYY-MM-DD
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Heart of Lorrimar Lodge
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