Client Intake Form

Our Geelong Disability Services Support Coordinator’s are there to make your life easier, leaving time and energy for the enjoyable things in your life.

Geelong's Trusted NDIS Registered Provider

Complete The
Client Intake Form

GDS Support Coordinators will assist you to understand and help to implement your NDIS plan. We can assist you in finding the right service providers for your needs, and coordinate all of your supports, including mainstream, informal, community and funded supports.

Client Name

Date of Birth

NDIS Number

Home Address

Suburb

Postcode

Mobile

Home Phone

Preferred Contact Method

Preferred Language

Is An Interpreter Required?

Gender

Pronouns

If Other, please specify:

Aboriginal/Torres Strait Islander?

Funding Agency

Agency Managed Plan Managed Self-Funded

NDIA Plan Starting Date

NDIA Plan Ending Date

Diagnosis

Type Of Enquiry

Services Required

Type of Referral

Role of Referrer

Does the Client give consent to be reffered to GDS?

Referrer Name

Relationship to Client

Referrer Address

Referrer Mobile Number

Referrer Home Number

Referrer Email

Referrer Preferred Contact