Client / Person completing this form Open Form Client / Person completing this form Name * Client Details First Name Last Name Date of Birth Phone Country (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred means of initial contact? * Choose from one of the below options Phone Call Phone Text Emil Is there any information you would like Cultivate Life Consulting to know about preferences or avoidances surrounding being contacted as there are times a Private Number is used. Services interested in: 1. Support Coordination: This service helps NDIS participants to understand and use you NDIS plan to pursue goals, support with NDIS Plan budgeting, NDIS Plan reviews and can connect you with NDIS providers, community, mainstream and other government services. Support Coordination 2. Psychosocial Recovery Coaching: A recovery coach is an NDIS funded worker that has mental health knowledge. A recovery coach will: spend time with you, and people important to you, to get to know you and understand your needs. Assist you to find out about different services and supports, and how these can help you. Psychosocial Recovery Coaching 3. Workshop Events: A targeted topic or activity that goes for 1.5-2hrs with light refreshment, and relevant supplies provided. This service can be for corporate groups, social groups, 1:1 and NDIS participant Workshop Events 4. NDIS Short Term Accommodation or Respite Coordination: Short Term Accommodation, including respite, is funding for support and accommodation for a short time away from an NDIS participants’ usual home. It covers the cost of your care in another place for up to 14 days at a time. You might have a short stay with other people, or by yourself. It’s often funded when your usual carers aren’t available, or for you to try new things. NDIS Short Term Accommodation or Respite Coordination 5. Allied Health Recommendation Occupational Therapy Psychology Speech Pathology Nursing Physiotherapy, Other 6. Support Work Recommendations Assistance with Social, Economic and Community Participation inc Recreational Activities Assistance with Daily Life Do you have a specific time, activity or preference for support or any other comment? Enter details below. Name of Person completing this form If you are completing this form on somebody's behalf, this section is for you. First Name Last Name Date of Birth Phone Country (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred means of initial contact Choose from one of the below options Phone Call Phone Text Email Is there any information you would like Cultivate Life Consulting to know about preferences or avoidances surrounding being contacted as there are times a Private Number is used. Thank you!
