PBS Request for Service Form

Step 1 of 6 – Personal Details

Personal Details

Your Name(Required)

Name Surname

Date of birth(Required)

Gender

Male

Female

Other

Prefer not to say

Your Address(Required)

Street Address Suburb Postcode

How Can We Reach You?

How can we get in touch?

Your Email Address(Required)

Your Phone(Required)

Best Time to Call You(Required)

Preferred Method of Contact(Required)

About You

This information will ensure we provide you the best support

Please tell us your primary disability

Secondary disablity

Other relevant medical conditions

Any Mental Health conditions

Are you of Aboriginal or Torres Strait Islander origin?

Yes

Are you from a culturally and linguistically diverse background

Yes

Language spoken

Do you require an interpreter

Do you have a criminal record

Yes

Prefer not to answer

If yes, please specify

Main Contact Details

Main Contact Person(Required)

Legal Guardian

NDIS Nominee

Name(Required)

Name Surname

Address(Required)

Same as previous

Street Address Suburb Post Code

Email(Required)

Phone(Required)

Do you have a Support Coordinator

Yes

Name(Required)

First Last

Agency(Required)

Phone(Required)

Email(Required)

PBS Information

Do you have a current behaviour support plan you would like to share with us?

Yes

Upload a copy of your plan here

Max. file size: 50 MB.

Do you have any restrictive practice reporting requirements?

Yes

Tick the statements that apply to you?

There are places you cannot go

There are items you cannot have including food

There are devices used for safety purposes i.e. seatbelt guards?

You have medication to control behaviour

Other

If yes, please specify

Do you have any of the following conditions

Epilepsy

Diabetes

Schizophrenia

Drug or alcohol addiction

Borderline Personality Disorder

Bi-Polar Disorder

Other

Funding Information

Funding source(Required)

NDIS Plan

Self Funded

I don’t have funding

Other

NDIS Number

Please attach a copy of your plan or evidence of funding here

Max. file size: 50 MB.

If you have not provided evidence of funding please tell us why?

Is the PBS funding allocation(Required)

NDIA Managed

Plan Managed

Self Managed

Person responsible for paying invoices(Required)

Name Surname

Organisation

Phone

Name of person confirming funding

Amount allocated

If proceeding, who will be signing the Service Agreement?

Referrer Name

Phone

Date

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.

PBS Request for services form

Personal Details

How Can We Reach You?

About You

Main Contact Details

PBS Information

Funding Information