Request for Service

Thankyou for accessing our Request for Service form. Please complete the details below. This will submit to our Customer Service Team who will contact you as soon as possible.

Request for Service Form

Step 1 of 13

What Golden City Support Service are you enquiring into?

Direct Supports

Exercise Physiology

Behaviour Support Practitioner

Hidden

Date of this Request

Contact Information

Who is the person requiring support?

Your Name(Required)

First Name Last Name

Gender

Male

Female

Indeterminate/Intersex/Unspecified

Date of Birth

DD slash MM slash YYYY

Contact Number

Do you identify as:(Required)

Address

Street Address Address Line 2 City State Post Code Country

Primary Contact Person

Who is the primary contact person if it is not the person requiring support?

First Name

Last Name

Mobile Phone

Contact Email(Required)

Relationship to person requiring support:

Would you prefer we contact you or your Primary Contact person?

Contact me - by phone

Contact me - by email

Contact my Primary Contact person - by phone

Contact my Primary Contact person - by email

Would you like to receive communication in the following formats?

Easy English

Plain Language

Consent

Who will provide consent?(Required)

Is there a guardianship order?

YES

What is their relationship to the person?

Contact Phone Number

Email Address

Preferred Method of Contact

Phone Call

Text Message

Has consent for the referral been obtained?

Written Consent

Verbal Consent

Date Consent was obtained

Your Disability and Health

Primary Disability(Required)

Secondary Disability

Cognitive Disability

Intellectual Disability

Neurological Disability

Physical Disability

Psychosocial Disability

Not applicable

What is your disability diagnosis? Please specify:

Do you have a mental health diagnosis? Please specify:

Do you have any ongoing health or medical issues? Please describe:

NDIA Support Co-ordinator or LAC

First Name

Last Name

Organisation

Contact Number

About your NDIS Supports

NDIS Number

Do you have an NDIS Plan?

YES

NDIS Plan Start Date

MM slash DD slash YYYY

NDIS Plan End Date

MM slash DD slash YYYY

If No NDIS Plan, is there other funding sources paying for supports?

How will the supports requested be managed through the NDIS Plan?

Participant

Participant Nominee

NDIA

Registered Plan Management Provider

Understanding your Support Needs

Support Needs

Support Level

Standard Supports

High Intensity Supports

Very High Intensity Supports

Ratio of Supports Required

1:2 (one staff member two clients)

1:1 (one staff member one client)

2:1 (two staff members one client)

Group based - Community

Group based - Centre

Other (please specify below)

If Other, Please Specify

Please tell us what NDIS goal the person is wanting to achieve:

Status and Reason for Referral:

Behaviour Support

Behaviour Support is not applicable to me

Not Applicable to me

Do you require support due to any of the following behaviours?

Property damage (attempt and causing property damage)

Absconding/leaving the residence

Physical aggression (e.g. hurting others)

Verbal aggression (e.g. threating language towards others)

Enter other people’s rooms

Self-injurious behaviour

Sexualised behaviour

Other

If other, please describe

Please briefly describe the impact of the behaviour on the person and/or on others

What environmental changes, structures and supports are needed to support the person to eliminate or reduce this behaviour?

Is this person currently on any restrictive behaviour interventions (e.g. medication for managing behaviour)?

What is the current state of a behavioural management plan?

Plan Completed

Plan Completed - Requires Review

No Plan - Needs to be Developed

No Plan - History Available

Behavioural Management Plan or History

Drop files here or

Max. file size: 48 MB.

Are there other providers involved?

Manual Handling

Manual Handling is not relevant to me

Manual Handling is not relevant

Do you use any equipment?

e.g. hoist, walking frame, wheelchair, commode, hearing aids, glasses

YES

If Yes, please describe

Do you need assistance using any equipment above?

YES

If Yes, please describe

Do you require assistance with your mobility?

i.e. moving from chair to bed or shower

YES

If Yes, please describe

Do you have a current Therapy Assessment?

YES

What supports are you interested in receiving?

Supported Independent Living

Bendigo

In Home / Community Based Support

In Home Supports

Community Based Supports

Details about In Home Supports request

Details about Community Based Supports request

Group Activites

We currently have limited availability to our group activities, however we can record your interest for future availabilities.

Drama

Art

Short Term Accommodation

Bendigo

Gisborne

Both / Either

Please describe the spread of hours - including days and times - that you are requesting(Required)

Funding

Funding to be allocated to Exercise Physiology Services:

12_027_0128_3_3 - Advise provided by an Exercise Physiologist regarding exercise required Quantity

Price: $ 166.99

Quantity

5_200_0128_1_3 - Assessment Recommendation Therapy or Training - Exercise Physiologist Quantity

Price: $ 166.99

Quantity

Funding to be allocated to Behaviour Support Services:

11_022_0110_7_3 - Specialist Behavioural Intervention Support Quantity

Price: $ 222.99

Quantity

11_023_0110_7_3 - Behaviour Management Plan Including Training in Behaviour Management Strategies Quantity

Price: $ 222.99

Quantity

Total Cost

Total

Privacy Details

Golden City Support Services (GCSS) manages privacy in accordance with The Australian Privacy Principles (APP) as issued by the Office of the Australian Information Commissioner and the Health Privacy Principles (HPP) laid down in the Health Records Act 2001 (Victoria) and other Federal and Victorian Acts that may apply. GCSS will take reasonable steps to protect personal information it holds from misuse, interference and loss, as well as unauthorised access, modification or disclosure. Where GCSS no longer needs the personal information for any purpose for which the information may be used or disclosed, GCSS will take reasonable steps to destroy or de-identify the information. A copy of the GCSS Privacy Policy can be made freely available by contacting the GCSS Privacy Officer on 5434 2777 or email privacy.officer.gcss@gcss.org.au.