Access NDIS Intake Form

Selective Support can provide assistance around your NDIS access application, free of charge. We will work with you to submit your NDIS application. If your application has been approved by NDIS, it is our hope that you choose to remain with Selective Support to implement and navigate your First NDIS Plan, however you are not under any obligation to continue being supported by Selective Support.

I Would Like Selective Support to Assist: *

1. Accessing NDIS for the first time.

2. My NDIS application was denied and need support with appealing decision.

NDIS Number

Date Denied:

Please note, NDIS is for participants under the age of 65. If over 65, please contact My Aged Care.

First Name *

Last Name *

Address *

City *

State *

Postal code *

Email

Phone *

Date of birth *

Support Person in My Life:

Name of Support Person:

Phone Number of Support Person:

Relationship:

Australian Citizen or Permanent Resident: *

Yes

No

Centrelink Benefits: *

Yes

No

Waiting for Benefits

Employed: *

Yes

No

List Diagnosed Health Conditions (Both Physical and Mental): *

I, (Participant) give Selective Support Pty Ltd permission to speak to: *

LAC and NDIA concerning my application

Treating professionals and/or organisations regarding my health condition