New Client Enquiry Form

This form is designed to collect some basic details from you, your representative, or a referral source.

Once submitted, a representative from Unlocking My Ability will contact you to discuss your support needs in more detail and guide you through the next steps of our intake process.

If you have any difficulty completing this form, please feel free to contact us and we can assist you over the phone.

Email: [email protected]
Phone: +61 449 966 624

Basic Information

Full Name of Representative/Referrer *

Who's filling out this form?

Relationship to Participant *

Father, Mother, Brother, Sister, Plan Manager, Support Coordinator etc.

Email of Representative/Referrer *

[email protected]

Phone Number of Representative/Referrer

Include country/area code (e.g. +61 4XX XXX XXX or 03 XXXX XXXX)

Participant Information

Participant Full Name *

Preferred name *

Address *

Street Address

City

State

Country

Postal Code

Email Address for Contact *

[email protected]

Participant/Representative Phone Number *

Best number to contact client or representative. Include country/area code (e.g. +61 4XX XXX XXX or 03 XXXX XXXX)

Date Of Birth *

Health & Support Information

Please state disability or medical conditions *

Does the client take any medication *

Yes

No

Use of Other Services

Does the participant have a behaviour support plan? *

Yes

No

Funding Details

Type of funding *

Self-Managed

Plan-Managed

NDIA-Managed

Self Funded

NDIS Number *

NDIS Plan Start Date *

Date your plan starts

NDIS Plan End Date *

Date your plan ends

Invoice Email *

[email protected]

Funding Details & Goals

Please state what services are required from Unlocking my Ability *

Please explain your goals and aspirations *

Final Details & Document Upload

Please upload any other documentation that may be of importance for us *

NDIS Plans, Doctor or other service provider supporting documents, etc.

Date Signed/Completed *

How did you hear about us? *

Participant / Referrer Signature *

Clear

Consent *

I agree to receive updates and service-related communications from Unlocking My Ability. I understand I can opt out at any time.