Participant Details

Participant Full Name *

Date of Birth *

Gender
—Please choose an option—MaleFemaleNon-binaryPrefer not to sayOther

Phone Number

Email Address

Address *

Best Mobile Number for Appointment Reminders

Description of Condition / Disability *

Relevant Medical History

Important Information for Sessions
Please include communication needs, behavioural tendencies, triggers, contraindications, sensory needs, or support preferences.

Mobility and Support Needs

Mobility Requirements

Walking independentlyWalking with aidsWeight bearingTransfers independentlyTransfers with assistanceSlide boardHoistManual wheelchairPower wheelchairWalkerWalking stickNo mobility assistance requiredOther

If other, please provide details

Does the participant require a support person to attend sessions?
—Please choose an option—YesNoUnsure

Please provide any additional support details

Participant Goals

What would the participant like to work towards?
This may include mobility, strength, balance, independence, confidence, pain management, community access, health, or maintaining current function.

NDIS Details

NDIS Number *

NDIS Plan Start Date

NDIS Plan End Date

How is the participant’s NDIS plan managed? *
—Please choose an option—Self-managedPlan-managedNDIA-managed

Does the participant have funding available for Exercise Physiology?
—Please choose an option—YesNoUnsure

Any relevant NDIS notes or funding information

NDIS Invoicing Details

If known, please let us know which NDIS support category or item number Exercise Physiology should be invoiced under. This helps us prepare the service agreement and invoices correctly.

Which funding category should Exercise Physiology be invoiced under?
—Please choose an option—Improved Health and Wellbeing - Category 12Improved Daily Living - Category 15Exercise Physiology specific item numberUnsure

If you know the specific NDIS item number, please enter it here

Any notes about how services should be invoiced?
For example, plan manager instructions, stated support category, quote requirements, or specific wording needed on invoices.

Plan Manager Details

Please complete this section if the participant is plan-managed.

Plan Management Company

Plan Manager Contact Name

Plan Manager Email

Plan Manager Phone

Support Coordinator Details

Support Coordinator Name

Company

Phone

Email

Emergency Contact

Emergency Contact Name *

Relationship to Participant *

Phone Number *

Email

Authorised Representative

Please tell us who is authorised to sign documentation, including the service agreement.

Who will be signing documentation? *
—Please choose an option—ParticipantParent / GuardianNomineePlan managerSupport coordinatorOther

Authorised Representative Name

Relationship to Participant

Phone

Email

GP Details

GP Name

Medical Practice

Phone

Email

Referral Information

How did you hear about us?

Internet / GoogleWord of mouthSupport coordinatorAllied health professionalGPSocial mediaExisting clientOther

Please provide details if relevant

Document Uploads

You can upload any relevant documents below. This may include NDIS plan goals, medical history, referral letters, medication list, behaviour support plan, or previous reports.

NDIS Plan Goals / Relevant NDIS Documents

Medical History / Referral Letter

Medication List or Other Supporting Documents

Form Completed By

Your Name *

Your Relationship to Participant *

Your Phone Number

Your Email *

Date Completed

I confirm that the information provided is accurate to the best of my knowledge and consent to Combined Wellness Solutions using this information to set up the participant in the system, prepare service documentation, and contact relevant parties where required.