Dietitian Online Waitlist Form

Thank you for choosing us and joining our waitlist for Dietitian Services.

To get started simply fill out the form below. Please note all fields marked with an asterisk (*) require an answer to continue.

Need help completing this form? Please contact us on on 1300 946 337.

The documents you will require to complete this form are:

NDIS Plan - if applicable

If Dietitian is already included in your NDIS plan, then there is no cost to you when you use NDIS Dietitan services.

Please read and ensure you understand our Privacy Policy here before completing this form.

Thank you and we look forward to working with you to achieve your goals.

Do you plan to access Dietitian with NDIS funding? *

Yes No

Do you have an NDIS plan? *

Yes - please complete the NDIS plan sectionNo

Do you intend to use private health insurance to access Dietitian *

YesNo

Is Dietitian on your NDIS plan? *

YesNo

Are you signing up for yourself or on behalf of an NDIS participant? *

Completing for myselfCompleting on behalf of an NDIS participant

Please specify your relationship to the NDIS participant *

Other - please specify* *

How did you hear about us? *

Please specify *

Why did you choose Windermere? *

Please specify *

1. Participant's Details

Please provide as many contact details as possible. At least one phone number is required.

Title

Given name(s) *

Surname *

Date of birth *

Gender *

MaleFemaleNon-identified

Street address *

Postcode *

Home phone

Mobile phone

Email address

My preferred contact method is:

EmailPhoneMobile

Your NDIS Plan

NDIS number *Your NDIS number is the 9 digit reference number located in the top left of your NDIS Plan

NDIS plan start dateYour NDIS start and end date can be found within your NDIS plan.

NDIS plan end date Your NDIS start and end date can be found within your NDIS plan.

NDIS plan provided (optional) *

YesNo

Windermere requests a copy of your NDIS plan to review and confirm the funding and support areas available.

Upload your NDIS plan here

Browse

File types accepted include .pdf, .doc & .docx, Max size 10mb. Upload is not mandatory but strongly encouraged.

If you do not have a copy of your NDIS plan or are experiencing difficulty in uploading your plan please call 1300 946 337 for assistance.

2. Authorised Contacts

Your contact details

Please provide as many contact details as possible. At least one phone number is reuired.

Given name(s) *

Surname *

Street address *

Postcode *

Home phone

Mobile phone *

Email address *

My preferred contact method is: *

EmailPhoneMobile

The participant has authorised me to:

Sign on their behalf

Share/discuss their NDIS plan

Enquire on their behalf only

Enquire and update on behalf of the participant

Release information on behalf of the participant

To be an emergency contact for the participant

No consents authorised, sharing information on behalf of the participant only

Authorise invoices on behalf of the NDIS participant

Does the Participant have an Authorised Representative? *

Yes No

Are you the Participant's Authorised Representative? *

Yes No

Authorised representative details

Please provide as many contact details as possible. At least one phone number is required.

Given name(s) *

Surname *

Organisation Name (if applicable)

Relationship to the NDIS Participant

This person is authorised to:

Sign on their behalf

Share/discuss their NDIS plan

Enquire on their behalf only

Enquire and update on behalf of the participant

Release information on behalf of the participant

To be an emergency contact for the participant

No consents authorised, sharing information on behalf of the participant only

Authorise invoices on behalf of the NDIS participant

Does the Participant have a Support Coordinator? *

Yes No

Are you the Participant's Support Coordinator? *

Yes No

Support Coordinator details

Please provide as many contact details as possible. At least one phone number is required.

Title

Given Name(s) *

Surname *

Email Address *

Phone Number *

Organisation Name (if applicable)

3. Invoice Authorisation

This section is for you to notify us who is able to authorise invoices on your behalf.

Please select who will be the primary person authorising all invoices *

MeParticipantAuthorised representative

Provider Contact Details

Provider: Windermere Child & Family Services

Phone: 1300 946 337
Email: ndis@windermere.org.au
Address: 48 Webb St, Narre Warren VIC 3805

5. Declaration

I hereby declare that the information given in this form is true and correct to the best of my knowledge/belief. *

I have read and understand Windermere's Privacy Policy here *

Please sign here *

Clear

Use your finger, stylus or mouse to draw your signature in the field above.

Name *

Date *

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