Social & Community Participation

Date Of Enquiry *

MM

DD

YYYY

Name Of Person Making Enquiry *

First Name

Last Name

Name Of Participant Wanting Social & Community Services *

First Name

Last Name

Phone Number Of Person Making Enquiry *

(###)

###

####

Relationship To Person Wanting Social & Community Service

Mother

Father

Brother

Sister

Relative

Friend

Support Coordinator

Other

Participant's Date Of Birth *

MM

DD

YYYY

Does The Participant Have An NDIS Plan?

Yes

No

Participant's Phone Number

(###)

###

####

Participant's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant's Preferred Communication Method *

Phone call

Email

Text

How Did You Hear About Us?

Family or Friend

Another Service Provider

Support Coordinator

Medical Professional

Specialist

Google

Facebook

Instagram

Newspaper

Radio

TV

Other

Name *

Please include participant's full name

First Name

Last Name

Name Of Person Completing Cancellation Form *

First Name

Last Name

Phone *

Please include your phone number so we can contact you if we require further information

(###)

###

####

What Date Do You Want To Cancel A Social & Community Shift *

Please note, Unique Directions may charge a cancellation fee as per the NDIS price guide specifications and the participant's individual service agreement

MM

DD

YYYY

What Time Was Your Shift Meant To Start? *

Hour

Minute

Second

AM PM

What Time Was Your Shift Meant To Finish? *

Hour

Minute

Second

AM PM

Participant's Full Name

First Name

Last Name

Date Form Completed *

MM

DD

YYYY

Is this a new support or a support that needs to be changed? *

Please tick the box

New support

Support that needs changing

Is this support a one-off occurrence or a regular occurrence? *

Please tick the box

One off shift

Regular

If this is a regular occurrence, please tick how often the support is to occur. *

If a one-off shift, tick N/A

Weekly

Fortnightly

N/A

Do you have enough funding in your NDIS plan? *

We recommend speaking to your Support Coordinator before completing this form if you are unsure

Yes

No

Can Unique Directions claim from your NDIS plan for this shift? *

If the answer is no, Unique Directions is unable to provide this support to you

Yes

No

What date do you want the shift to commence? *

MM

DD

YYYY

What time do you want the shift to begin? *

Hour

Minute

Second

AM PM

What time do you want the shift to finish? *

Hour

Minute

Second

AM PM

What is the pick up location? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is the drop off location? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you attending a special event during this time? *

For example: Presentation night, Special Olympics

Yes

No

Start Time Of Event

Hour

Minute

Second

AM PM

End Time Of Event

Hour

Minute

Second

AM PM

Address Of Event

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Full Name Of Person Completing Form *

First Name

Last Name

Did a Support Worker assist you to complete this form? *

Yes

No

Full Name Of Support Worker

First Name

Last Name