Prior to your first NDIS Session, please complete the following form which provides us with the information to tailor a package which is both appropriate and safe. This will also be used to create an account in our system should you wish to continue with regular sessions. Please also refer to our Privacy Policy.

Client

The person with a disability

Enter the name of the NDIS participant matching the NDIS number you are specifying. Our records will be filed under this name and invoices issued to this name.

Please use format DD MMM YYYY (eg. 06 Aug 1995) or click on the calendar symbol (far right) to select day directly (click on calendar widget header bar to change the date range/scale)

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

High functioning independent participants above the age of 18 may have their own contact details. 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.

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. Note that for regular invoiced sessions we prefer to book in school term blocks.

By default, we do not specify our registered NDIS Price Guide line item (09_008_0116_6_3) which will allow self-managed and some plan-managed participants to access funding from a number of different budgets including core. Alternatively if you have this category in your plan, we can specify it on the invoice. We can also put other text/line items on the invoice if required.

Regular Carer

Contact details of regular carer who will accompany the client

Please select the option that best describes the carer that may accompany the client for each visit. Please refer to the Responsibilities section of our Service Agreement for our requirements.

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

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

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.

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 description of any known medical issues that could lead to problems in a farm environment. Include Known 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.

You may provided a summary of the goals for your visits(s) to Trevena Glen. Alternatively you may attach a file or discuss them with our facilitator during your visit.

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 3 files, 10MB each). If choosing multiple files, do them at the same time using Ctrl-click.

Confirmation and submission

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

PLEASE NOTE: Once you submit the form, please check your page for a message in green that indicates the form has been submitted successfully (you may need to scroll to see this message). You should also receive a confirmation email. If you have an error message, please check:

  • The mandatory fields (with red asterix) have been filled in

  • The birth date field is in the right format

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

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

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