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UME NDIS CLIENT FORM
Self & Plan Managed Clients Only
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* Indicates required question
Client Name
*
Your answer
Client ID No.
Your answer
Date Of Birth
*
MM
/
DD
/
YYYY
Client Phone No.
*
Your answer
Presenting Issues
*
Anxiety
Thinking Actual Self Harm
Depression
Self Harm
ADHD
ADD
Autism
Learning Disabilities
Physical Disability
Required
Which of the following activities are you interested in?
*
Music Production
Music Industry
DJ Lessons
Radio/Podcasting
Drums/Bongos
Guitar Lessons
Mentoring
Capacity Building
Social Engagement
Work Readiness
Required
Specify Issue
Your answer
Risk Management
Your answer
Desired Outcome from Engagement
Your answer
Is this person NDIS ELIGIBLE?
Yes
No
Clear selection
Does this person have an NDIS Plan currently in place?
Yes
No
Clear selection
When is the current plan valid until?
*
MM
/
DD
/
YYYY
Does this person have an external support co-ordinator?
Yes
No
Other:
Clear selection
Name of co-ordinator/FLO case manager
Your answer
Name of Organisation
Your answer
Phone No of co-ordinator/FLO case manager
Your answer
Email of co-ordinator/FLO case manager
Your answer
Consent to Contact co-ordinator/FLO case manager?
Yes I authorise UME to contact the above named person/organisation.
No I do not authorise UME to contact the above named person/organisation
Clear selection
Plan Managers/Person Responsible Email for Invoicing Purposes
Your answer
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