Menu
1800 887 688
Request for Service Form
Request for Service Form
WORD
-
PDF
PLEASE USE 1 FORM PER PERSON
ENSURE YOU ENTER CORRECT CONTACT DETAILS
Date of Request
Requested By:
On own behalf
By another party
SECTION A – DETAILS OF PERSON REQUIRING ASSISTANCE
Full Name
Street Address
Telephone
Date of Birth
Email
Age
Gender
Male
Female
Non-Binary
List all Diagnosed Permanent Disabilities:
PLEASE DO NOT LIST COMPLEX MEDICAL OR HEALTH CONDITIONS
Indigenous Status:
Neither Aboriginal nor Torres Strait Islander
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Cultural Background:
English Speaking Background
Non-English Speaking Background
English as 2nd Language
Language Spoken at Home
NDIS Participant:
Yes
No
Currently Seeking Access
Current Living Situation
Own
Private Rental
Public Housing
Group Home
Homeless
Other
Describe living situation if other
Appointed Decision Makers:
Power of Attorney/Enduring Power of Attorney
Office of Public Guardian/Other QCAT appointed Guardian
Public Trustee/Other QCAT Appointed Financial Administrator
NDIS Plan Nominee
SECTION B – DETAILS OF OTHER PARTY MAKING REQUEST
Your Name / Organisation’s name
Your relationship with the person
Contact Number
Contact Email
Does the person know, understand and consent to you making this request?
Yes
No
SECTION C – ISSUE/S
Please give an overview of why advocacy is needed
SECTION D – STEPS ALREADY TAKEN
Please describe of what steps have already been taken to try and resolve these issue(s)
SECTION E - OUTCOMES SOUGHT
Please describe the outcomes you want an advocate to help you achieve
SECTION F – TIME FRAME OF NEED FOR ADVOCACY
If any of your issues need to be addressed by a particular date, please list the date(s) here
Home
About Us
Mission & Vision
History
Committee & Staff
Accreditation
Services
Individual
Disability Royal Commission
Self Advocacy
Systemic
Service Request Form
NDIS
You and the NDIS
Planning Tools
Complaints and Reviews
NDIS Resources
Get Involved
Donations
Employment
Membership
Partnerships
Volunteering
Latest News
Events
Covid 19
Resources
Governance
Forms
Links
Papers and Reports
Contact