UCWB – Support Coordination Intake Form

Welcome to UCWB – NDIS Support Coordination

To register for Support Coordination services with UCWB, please complete the Intake Form.

We ask that you also include copies of your NDIS Plan, any relevant reports, and other supporting documentation.

We’re here to help – don’t hesitate to give us a call on 0499 583 288 if you have any questions.

Who Will Receive The Service

First Name *

Last Name *

Date of Birth *

Phone Number

Email

Address *

Street Address *

City *

State *

Postcode *

Gender *

ATSI

Disability / Diagnosis *

Preferred Name

Preferred Pronoun

Preferred Language

Preferred Communication *

Interpreter Requirements

Cultural Requirements

Referrer Details

Self ReferralThird Party Referral

First name *

Last name *

Phone Number *

Email address *

Address

Street Address

City

State

Postcode

Relationship *

Organisation

Legal Documentation

If you have any legal documents, you'd like to share with UCWB, please complete this section.

These documents can help us develop a more comprehensive support plan and ensure we provide the best possible care.

They may also be important to share with emergency services or medical personnel if needed in an emergency.

Forensic/Court OrdersAdvanced Care DirectivePower of AttorneyTribunal / Guardianship/SACAT Order

Attached

Browse

Decision-Maker Details (if applicable)

First Name

Last Name

Phone Number

Email

Address

Street Address

City

State

Postcode

Relationship

Capacity as decision maker

Tribunal / Guardianship/SACAT OrderPower of AttorneyNDIS plan nomineeParent (of child under 18)Informal Representative ( Please note: An informal representative cannot sign documents on your behalf but may be involved indiscussions regarding your care plan )

Funding Details

NDIS Number *

Start Date of NDIS Plan

End Date of NDIS Plan

SC Funding Management *

NDIA ManagedPlan Managed Self Managed

"If you are plan-managed or self-managed, please specify below where invoices should be sent"

Name

Email

Phone Number

NDIS Plan / Goals *

Plan AttachedGoals Attached (a copy of the goals to be attached at a minimum)Do not wish to share funding information

Attach Documents

Browse

NDIS Support Category *

Level 2 Support CoordinationLevel 3 Specialist Support Coordination

Your NDIS plan should indicate whether you have been allocated Support Coordination or Specialist Support Coordination

SC Funding available:Please enter the SC funding available, if known

Care Team Details

Name

Role

Phone Number

Email

Additional Notes

You may wish to include any background information that could help us match you with the most suitable Support Coordinator. This might include any risks, additional reports, or other details that could support your care planning.