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159 Raeburn Street, Manly West Queensland

admin@care-nation.com.au

0493 456 678

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Care Nation is Here to Help

We’re here to support you every step of the way. This form allows us to learn more about you, your goals, and the type of support you’re looking for, so we can tailor our services to you. It also includes important consent information to ensure your privacy and choices are respected.

Is the Participant Over 18 Years?*

Yes

No

Carer/Parent Details

First name*

Last name*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Participant Details

Participant's First Name*

Participant's Last Name*

Participant's Preferred Name*

Participant Address*

Participant's Phone*

Participant's Email*

Participant's Date of Birth*

Month

Day

Year

Participant's NDIS Number*

Participant's NDIS Plan Start and End Dates*

Emergency Contact / Next of Kin

Emergency Contact's First Name*

Emergency Contact's Last Name*

Emergency Contact's Relationship to Participant*

Emergency Contact's Phone*

Emergency Contact's Email*

NDIS Plan Details

NDIS Plan Type*

Self-managed

Plan-managed

NDIA-managed

Plan manager details (if applicable)

Support coordinator details (if applicable)

Participant Goals & Interests

What are your goals?*

What would you like support with?*

Interests / hobbies / Preferred Activities*

Support Needs & Preferences

Type of support required*

Community participation

Daily living

Transport

Social support

Accommodation

Other

Select Multiple if required

Preferred days/times*

Cultural or religious considerations*

Health & Safety Information

Medical conditions and Allergies*

Medications (optional or summary)*

Behavioural, Mobility and Communication support needs*

Upload Medical Documents

Risk & Safety Acknowledgement

Any risks staff should be aware of*

Emergency instructions*

Consent for emergency medical treatment*

Consent to Provide Services

I agree to receive services from Care Nation

I understand services are delivered under my NDIS plan

I understand I can stop services at any time

Privacy & Information Consent

I consent to my information being collected and stored

I understand my information is kept confidential

I can withdraw consent at any time

Consent to Share Information

Tick all that apply*

Plan Manager

Support Coordinator

Allied health professionals

Family / Guardian

Consent for Photos / Media

Consent for photos

Yes

No

Tick all that apply

Social media

Website

Marketing

Service Agreement Acknowledgement

By signing below your agree to our Terms & Conditions and Privacy Policies

Participant/Carer Full Name*

Date picker*

Signature

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Need Help or Want to Help?

Whether you are looking for support or offering it, we would love to hear from you.

CONTACT US

0493 456 678

admin@care-nation.com.au

159 Raeburn Street, Manly West Queensland 4179

Care Nation proudly operates on the traditional lands of the Turrbal, Jagera, and Quandamooka people. We pay our respects to the Elders past, present, and future, and acknowledge the ongoing connection of First Nations people to the land and water on which we work.
Care Nation welcomes all the members of the LGBTQIA+ community.

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