Become an Enable Client Please fill out all of the below fields to the best of your ability. If you need assistance, please ask a Guardian, Support or relative to help. The more information you provide, the better Support and Service we can plan. Enquirer's Details If you are filling out this application for yourself, or on behalf of a family member, friend or client, please fill in all fields below. Enquirer's Name (required) You are required to enter at least ONE contact method: Enquirer's Email: Enquirer's Phone Number: Enquirer's relationship to the potential client: (required) Suburb/city of the potential client: (required) Which of our Enable offices are closest to the potential client? (please select one) ---ManjimupBusseltonBunburyAustralindMandurahRockinghamSouth PerthNorth Perth How did you hear about us? ---Word of MouthSocial MediaAn ad on GoogleReferred to from other providerAn EventNewspaper Ad/StoryOther If you answered 'other', please describe here: Potential Client's Details Please fill out in as much detail as possible, so we can gain a deep understanding of your needs. Potential Client's Name (required): Potential Client's Date of Birth: Potential Client's Address (required): You are required to enter at least ONE contact method for the potential client: Potential Client's Email: Potential Client's Phone Number: Potential Client's Preferred Contact Method: (please select one) EmailPhone CallText/SMS Are you of Aboriginal or Torres Strait Islander origin? ---YesNo Please advise your diagnosis/disability. This helps us understand how best to support you.(required): Tell us in 100 words or less about yourself: How do you communicate? Do you require assistance with communication? Do you require access to interpretation services? ---YesNo What is your country of Birth? What is the main language spoken at home? Do you have any religious or cultural requirements you would like us to be aware of? Please describe any in the field below: Have you received services previously from Enable WA or another service provider? ---I've been with Enable WA beforeI've been with another providerThis is my first time seeking support If you have been with a different provider previously, please explain why you're changing. What Support Looks Like For You What does Support look like for you on a weekly basis? Please give as much information as possible. What days would you be requiring Support for? MondayTuesdayWednesdayThursdayFridaySaturdaySunday What hours would you be needing Support? Would you be interested in accessing any of our Therapy services? If so, select which ones below: Occupational TherapySpeech PathologyPhysiotherapyPsychology ServicesPositive Behaviour SupportNone Is there a Legal Guardian or Public Trustee involved in your Support needs? (please select) ---Legal GuardianPublic TrusteeBothNeither Is there any Child Protection and Family Support (CPFS), or Department of Communities (DoC) involvement: (please select) ---YesNo Is there any involvement with the Department of Justice? (please select) ---YesNoPreviously Is this a new NDIS Plan? ---YesNo Are there any Accommodation Supports included in your Plan? Do you have a Support Coordinator? ---YesNo If you answered 'yes', provide their name and contact details: Do you have a Plan Manager? ---YesNo If you answered 'yes', provide their name and contact details: Please answer these as accurately as possible, so we can understand how best to help you or the person you're applying for. Are there any behaviours of concern? How do these present? Is there a Positive Behaviour Support plan in place? ---YesNo Are there any Restrictive Practices? ---YesNoUnsure Do you have any medical conditions? If so, how are these managed? Do you have a preference for Support Workers? ---Female OnlyMale OnlyNo Preference Are there any other agencies involved in your Plan? If so, please leave information on who they are: Your NDIS Plan Please upload your NDIS plan so we can assess your needs. All files must be in either PDF or .docx format, and under 10mb to be uploaded. Supporting Documents Please upload any Therapy Reports, Medical Reports or Function Capacity Assessments you may have. All files must be in either PDF or .docx format, and under 20mb to be uploaded.