NDIS Enquiries Form

Thank you for your interest in enquiring about our NDIS Services.

Please complete this form and our consumer response officer will call you within 2 business days.

Are you enquiring: *

For yourselfAs Parent / CarerAs Referrer / Other (Please specify)

Please select the most appropriate *

Organisation Name: *

Referrer First Name: *

Referrer Last Name: *

First Name *

Last Name *

Contact Details

If you are the contact person for this NDIS Participant, please provide your details below. Otherwise, please provide the best contact person details.

Please provide your details below, or alternatively the best person to contact.

Contact Person First Name *

Contact Person Last Name *

Relationship to NDIS Participant *

NDIS Participant Details

NDIS Participant First Name *

NDIS Participant Last Name *

Preferred Method of Contact *

Phone NumberEmail Address

Email Address *

Phone Number *

Alternative Phone Number

Preferred contact time *

AMPMAnytime

Please state which NDIS service/s you are enquiring for *

NDIS Pre-PlanningNDIS Plan ManagementNDIS Support CoordinationNDIS Early Intervention/Key WorkerNDIS CounsellingNDIS DietitianNDIS Occupational TherapyNDIS PhysiotherapyNDIS PsychologyNDIS Speech PathologyNDIS Information SessionNDIS Group and/or School Programs (Please specify which program in the comment box below if applicable)Other

Please specify *

How did you find us? *

Please specify *

Other notes

Thank you for your referral. If you are not the contact person but wish to know the referral outcome, please include your contact details in the comment box above.

Windermere takes your privacy seriously. We have policies and safeguards in place that comply with the Privacy Act 1988 (Commonwealth), the Privacy and Data Protection Act 2014 (Vic), and the Health Records Act 2001 (Vic).

For more information on how we protect your privacy, click this safe link Privacy Policy | Windermere

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