Participant Enquiry Form

Participant First name

Participant Last name

Email

D.O.B

Primary Contact Name/Relationship

Location

Phone

Gender

Female

Male

Other

Type of Disability

What type of supports do you require?

1:1 (High support needs)

1:2 (Moderate support needs)

1:3 (Low support needs)

1:4 (Lower support needs)

What type of service do you require?

Community Participatioin

Assistance with Daily Life

Short Term Accommodation (STA)

NDIS Plan

NDIS Number (If applicable)

I understand that Mindful Disability:

Does not provide support for participants with complex/violent behaviours.

Does not provide support for participants with higher needs.

Provides support for participants aged 18-35 years.

Provides a minimum of 4 hours of support.

Scope of Services.

* Participants may have mixed or secondary support needs; however, our services are only suitable where support goals align with social participation, independence, and life-skill development.