request for services 2023

Request for Services

Please complete the below questions and a member of our team will be in touch to discuss the services you would like to access.

Client/Participant Name *

Gender

MaleFemaleOther

Date of Birth *

If 'other' please detail:

Diagnosis *

How will you be funding the services? *

NDISFee for service (I will pay for them myself)Other

If 'other' please detail: *

NDIS Participant Number *

NDIS plan start date *

NDIS plan end date *

NDIS Plan (Please attach)

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You can access a copy of your NDIS Plan by logging into your MyGov account and clicking on the National Disability Insurance Scheme icon: https://my.gov.au/

How are you managing your NDIS funds? *

Plan Manager name and email

Contact Details

Name *

Relationship to client/participant? (eg Self, Parent, Support Coordinator) *

Address *

Suburb *

State *

Postcode *

Best contact number *

E-Mail Address

Kindergarten / Childcare / School / Other

Other Attendance

Kindergarten Name

Kindergarten Address

Kindergarten Suburb

Childcare Name

Childcare Address

Childcare Suburb

School Name

School Address

School Suburb

Services and Supports offered

If Other

Other

Preference/s for days and times to receive servicesPlease note: Autism SA endeavours to ensure your preferences are considered however due to timetabling may not always be available and cannot be guaranteed. Clinical Services are currently offered Monday to Friday 9am-5pm.

Monday Time Start availablity

Monday Time Finish availablity

Tuesday Time Start availablity

Tuesday Time Finish availablity

Wednesday Time Start availablity

Wednesday Time Finish availablity

Thursday Time Start availablity

Thursday Time Finish availablity

Friday Time Start availablity

Friday Time Finish availablity

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