Participant Name Date of Birth Address Suburb State Postcode Phone Email
Plan Number Plan Start Date Plan End Date
Which section of the plan are you wishing to claim funds from?
Improved Daily Living Skills (Capacity Building)Health and Wellbeing (Capacity Building)Daily Activities (Core Supports) How many hours would you like to set aside? (Required)
How do you manage the plan? (and how do you arrange payment for services)
Self Managed (pay cash, EFT or invoice)Agency Managed (Portal)Plan Managed Name of Plan Manger Organisation Email invoice to Contact Number
Have you added Optimum Intake as a My Provider in your NDIS plan (for plan or agency managed participants only)?
YesNo
Where would you like services provided? (Please note that where safety is a concern clinic visits are required).
Clinic (Tuggerah, Broadmeadow, Port Stephens)Home visit
If Home visit: Is this accommodation a Group Home/SIL?
Reason for seeing the Dietitian:
Is this person fed via a PEG?
Safety Questions. Where a safety risk may be present, we may limit services to clinic-based services only.
Is this participant in control of their behaviour at all times?
Does this participant use recreational drugs in the home?
Does this participant have a history of violence or aggression?
Will a Support Worker or other representative be present during all visits?
Please provide any other information you think we may need in relation to safety or visits here:
Full Name
Relationship
Phone
Email
ParticipantParent/GuardianOther Full Name
Is there anything else you feel we should know before booking the first appointment?
Yes (if yes list below)No
Attach any relevant documents (Optional)
