Please complete the following form so that we can create a client account in our system that will facilitate invoicing and access to our customer portal.

A) Client

The person participating

Enter the name of the participant. Our records will be filed under this name and invoices issued to this name. This form collects details for ONE individual. If you have more than one participant, please complete a separate form submission for EACH participant.

Please click on the calendar symbol (far right) to select day directly (click on calendar widget header bar to change the date range/scale). If entering manually, you MUST use format DD MMM YYYY (eg. 06 Aug 1995) using 3-LETTER abbreviation for the month.

Please tick all that apply (up to a maximum of THREE). Note that the NDIS session can include interaction with any of our farm animals including horse riding whereas the EAL session ONLY includes horse activities with a specialised instructor.

Please indicate who will fund and ultimately pay for the service provided. For NDIS funded services you must provide an NDIS number and will receive GST free invoices - a later questions will ask how your plan is managed.

For horse riding we need an approximate weight in order to select an appropriate horse. Enter the number of kgs.

Must be provided in order for us to issue GST free invoices to be claimed from NDIS

High functioning independent participants above the age of 18 may have their own contact details and often visit the farm on their own. In this case, answer 'Yes' to this question.

NOTE: Please ONLY complete this field if the client has their own personal mobile phone which is DIFFERENT to that of the primary contact.

NOTE: Please ONLY complete this field if the client has their own email address which is DIFFERENT to the primary contact.

B) Responsible Person

Name of parent, guardian with primary care responsibility for the client

A mobile phone contact is required to enable us to arrange late cancellations etc due to weather, staff availability, etc.

An email contact is required for issues relating to service agreements, bookings, and invoices

Please indicate your relationship to the client. This might be parent, child, guardian, carer, support coordinator, etc.

Select which payment options apply for your first and potentially regular sessions. Tick all that might apply. For NDIS funded sessions we prefer to book in school term blocks and if you are plan managed you should select "invoice after each session" only. For regular self-funded bookings (Riding, Horsemanship), invoice school term in advance is the only option.

By default, we do not specify an NDIS line item on the invoice. Answer yes if you or your plan manager needs to have the line item specified on the invoice - we are registered for 09_008_0116_6_3 so select this ONLY if you have funding for this line item in your plan, otherwise select the specify option and define which line item you would like the funding to come from. Note that many have CORE funding available in 04_104_0125_6_1 (Community, Social and Rec Activities).

Specify the line item to appear on the invoice from which funding for the visit should be taken. NOTE: If you don't know, you may need to ask your Support Coordinator or your Plan Manager.

C) Regular Carer

Contact details of regular carer who will regularly accompany the participant on visits to the farm. Please advise us by email if you would like to provide us with details for more than one regular carer.

Please select the option that best describes the carer that may accompany the participant for each visit. For NDIS participants, please refer to the Responsibilities section of our Service Agreement for our requirements.

Refer to Service Agreement

Provide an email contact if you would like the carer to be able to access our online system

D) Support Coordinator

You can provide details of a support coordinator who will monitor your plan and advise on how to get the most from your supports.

The business name of the support coordinator if relevant

E) Plan Manager

Who is responsible for administering your NDIS plan and payment of invoices

Which of the three available options are you using to manage your NDIS plan - refer https://www.ndis.gov.au/participants/creating-your-plan/ways-manage-your-funding

Provide the name of a contact person (if known)

Please provide an email address where invoices should be sent for payment

Invoices will be sent to the primary contact
NOTE: We are currently NOT able to host clients with a NDIA-managed funding plan. Please continue to submit this form if you would like to register your interest in our program. We will contact you when we are able to invoice the NDIA directly and offer our services to you.

F) Extended Client Details

Please supply as much information as possible to ensure that we can tailor an appropriate and safe program for the client.

Please provide a summary of the goals for your visits(s) to Trevena Glen. Be specific if possible - ie. top 5 goals for your sessions. You may also attach a file (subsequent question).

Please provide a description of any known medical issues that could lead to problems in a farm environment. Include conditions for which medication is given regularly, bleeding abnormalities, allergies, physical disabilities, etc.

Please provide details of any tendencies that would not be regarded as "normal" such as anxiety, reactions to events, tendency to run/hide, phobias, etc. Include challenges that you would like to work on during your sessions.

You may upload relevant files (eg. NDIS plan goals) if you think this will help us to customise a program for your sessions or have a better understanding of the participant. Only pictures (JPG), screenshots (PNG), and PDF files allowed (max of 5 files, 10MB each). If choosing multiple files, do them at the same time using Ctrl-click.

G) Confirmation and Submission

Please tell us how you first heard about our farm programs

Please specify the other way you heard about Trevena Glen services

Please refer to the following relevant documents (clicking on the links will open the document in a new tab leaving form data unaltered):

PLEASE READ VERY CAREFULLY:

You MUST click the Submit button for the form data to be submitted (shown below once you click "Yes" to indicate you have read and agreed with the relevant documents provided above). DO NOT leave this page until a GREEN message is displayed otherwise your information will NOT be recorded.

Once you submit the form, please check your page for a message in green that indicates the form has been submitted successfully (this should be at the bottom of the form). This message can take a few seconds to appear so wait until the the small activity circle stops rotating. Once successfully submitted, you should also receive a confirmation email.

If a green message does not appear, you will need to scroll up to see error messages in red). If you have an error message, please check:

  • The mandatory fields (with red asterix) have been filled in. If you don't have anything to put in the field, write "None" or "N/A".

  • You have provided VALID email addresses (eg. alan@trevenaglen.com.au).

  • The birth date field is in the right format - note that the month needs to be the 3-letter abbreviation, NOT written out in full. Example "01 Jan 2023"

If you have any difficulties, print the page to a PDF and email it to admin@trevenaglen.com.au

PLEASE NOTE: You will only be able to submit the form if you answer yes.

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