NDIS PARTICIPANT NEW ENQUIRY FORM

NDIS PARTICIPANT NEW ENQUIRY FORM

What Service Are You Requiring?

AssessmentTherapy

NDIS Participant First Name *

NDIS Participant Surname Name *

Is the participant aware that you are making this referral *

NDIS Participant Phone Number *

NDIS Participant Date Of Birth *

NDIS Number *

NDIS Participant Email Address

Please State the Reason For the Participant Being on NDIS *

Support Coordinator Name (if any)

Support Coordinator Organization name (if applicable)

Support Coordinator Email (if any)

Support Coordinator phone number (if any)

Date *

TYPE OF NDIS PLAN

SELF MANAGED - The client / client representative has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, PsychCare Psychology will send the client / client representative an invoice for those supports for the client / client representative to pay. The client / client representative will pay the invoice by direct debit / EFT within 7 days. NDIA MANAGED - The client has nominated the NDIA to manage the funding for supports provided under this Service Agreement. After providing those supports, PsychCare Psychology will claim payment for those supports from the NDIA. PLAN MANAGED - The client has nominated the Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, PsychCare Psychology will claim payment for those supports from

Plan Manager Provider Name

Plan Manager Email Address

Funding Available for Psychology on this current plan *

NDIS Plan Start Date *

NDIS Plan Finish Date *

Frequency of support *

WeeklyFortnightlyMonthly As scheduled

Price & Payment Information

Psychology Therapy will be charged at

$214.41 per hour for a clinical or registered psychologist
$193.99 per hour for a provisional psychologist

Name of Person Submitting this Form *

Relationship of Person Completing this Form to NDIS Participant *

Email of Person Submitting this Form *

Phone Number of Person Submitting this Form *

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