NDIS Full Registration

Participant Details

First Name*
Please enter your first name.
Please enter your first name.
Last Name*
Please enter your last name.
Please enter your last name.
Gender*
  • - select an option -
  • Female
  • Male
  • Other
Please enter your gender.
Please enter your gender.

Date of Birth*

Day
  • - enter the day -
  • 1
  • 2
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  • 3
  • 5
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  • 8
  • 9
  • 10
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  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Please enter the participant's date of birth
Please enter the participant's date of birth
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please enter the participant's date of birth
Please enter the participant's date of birth
Year
Please enter the participant's date of birth
Please enter the participant's date of birth
NDIS Number*
Please enter the participant's NDIS Number.
Please enter the participant's NDIS Number.
Does the Participant Identify as Aboriginal or Torres Strait Islander?*
Please answer the question.
Please answer the question.
Street Address*
Please enter the participant's street address.
Please enter the participant's street address.
Suburb*
Please enter the participant's suburb.
Please enter the participant's suburb.
Post Code*
Please enter the participant's post code.
Please enter the participant's post code.
State*
  • - select an option -
  • Victoria
  • Queensland
  • New South Wales
  • South Australia
  • Tasmania
  • Western Australia
  • Northern Territory
  • Australian Capital Territory
Please select the participant's state.
Please select the participant's state.
Mobile Phone
Please enter the participant's mobile phone number.
Please enter the participant's mobile phone number.
Home Phone
Please include the area code
Field is required!
Field is required!
Email
Please enter the participant's email.
Please enter the participant's email.
Is the person filling in this form the participant?*
Please answer the question.
Please answer the question.

Parent/Guardian

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below
First Name
Please enter your partner's first name.
Please enter your partner's first name.
Last Name
Please enter your partner's last name.
Please enter your partner's last name.
Gender
  • - select an option -
  • Female
  • Male
  • Other
Please enter your partner's gender.
Please enter your partner's gender.

Date of Birth

Day
  • - enter the day -
  • 1
  • 2
  • 3
  • 3
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Field is required!
Field is required!
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Field is required!
Field is required!
Year
Field is required!
Field is required!
Relationship to Participant
Field is required!
Field is required!
Street Address
Please enter your street address.
Please enter your street address.
Suburb
Please enter your suburb.
Please enter your suburb.
Post Code
Please enter your post code.
Please enter your post code.
State
  • - select an option -
  • Victoria
  • Queensland
  • New South Wales
  • South Australia
  • Tasmania
  • Western Australia
  • Northern Territory
  • Australian Capital Territory
Please select your state.
Please select your state.
Mobile Phone
Please enter your partner's mobile phone number.
Please enter your partner's mobile phone number.
Work Phone
Please include the area code
Field is required!
Field is required!
Email
Please enter your partner's email.
Please enter your partner's email.

Health Information

Medical Conditions

Disability / Medical Conditions including any diagnosis if relevant*
Limit of 200 characters
Please enter the disability/medical conditions and limit your answer to 200 characters (including spaces).
Please enter the disability/medical conditions and limit your answer to 200 characters (including spaces).
Participant Strengths/Capabilities*
Limit of 200 characters
Please enter the participant strengths/capabilities and limit your answer to 200 characters (including spaces).
Please enter the participant strengths/capabilities and limit your answer to 200 characters (including spaces).
Any Allergies?*
Please answer the question.
Please answer the question.
Details of Allergies
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Any Special Dietary Requirements?*
Please answer the question.
Please answer the question.
Details of Dietary Requirements
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Hobbies, interests, passions, mobility status, developmental milestones (fine and gross motor skills), personality traits*
Limit of 200 characters
Please fill in details and limit your answer to 200 characters (including spaces).
Please fill in details and limit your answer to 200 characters (including spaces).

Medication

Medication Required*
Please answer the question.
Please answer the question.
Prompt Required*
Please answer the question.
Please answer the question.
Assistance Required*
Please answer the question.
Please answer the question.
Administration Required*
Please answer the question.
Please answer the question.
Medication Details and Instructions
For example, type of medication, frequency, dosage and schedule) (the participant/advocate will provide training and direction on procedures to each support worker (Limit of 200 characters)
Please limit your answer to 200 characters (including spaces)
Please limit your answer to 200 characters (including spaces)

GP

Contact Type
Field is required!
Field is required!
Full Name*
Please enter the doctor's full name.
Please enter the doctor's full name.
Company Name*
Please enter the doctor's company name.
Please enter the doctor's company name.
Landline Phone Number*
Please include the area code
Please enter the doctor's landline phone number.
Please enter the doctor's landline phone number.
Email*
Please enter the doctor's email.
Please enter the doctor's email.
Postal Address*
Please enter the doctor's postal address.
Please enter the doctor's postal address.
Please indicate the type of information to share with this contact*
  • - select an option -
  • Financial only
  • Medical and Care Related only
  • All of the above
Please select.
Please select.

Position Information

NDIS Plan

Plan Type*
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
NDIS Plan Budget (amount you are planning to spend on this service)*
Please enter the budget.
Please enter the budget.

NDIS Plan Start Date*

Day
  • - enter the day -
  • 1
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  • 3
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  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Please enter your commencement date
Please enter your commencement date
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please enter your commencement date
Please enter your commencement date
Year
Please enter your commencement date
Please enter your commencement date

NDIS Plan Finish Date*

Day
  • - enter the day -
  • 1
  • 2
  • 3
  • 3
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Please enter your commencement date
Please enter your commencement date
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please enter your commencement date
Please enter your commencement date
Year
Please enter your commencement date
Please enter your commencement date
Upload your documents...
Field is required!
Field is required!

Registration Groups

Look on our website for a description of the registration groups https://www.alhca.com.au/ndis/
Which registration groups would you like?
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Please give a description of the support required*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Please list your goals, specific needs, daily routines and support requirements*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Please list your family lifestyle matters, culture, diversity, values and beliefs*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
What needs, specific skills, responsibilities or qualities do you value in your support worker?*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).

Required Hours*

Let us know what hours you would like support.

Monday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Tuesday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Wednesday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Thursday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Friday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Saturday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!

Sunday

Shift 1 Start Time
Field is required!
Field is required!
Shift 1 Finish Time
Field is required!
Field is required!
Shift 2 Start Time
Field is required!
Field is required!
Shift 2 Finish Time
Field is required!
Field is required!
Will this be the same time each week on a regular basis?*
Please answer the question.
Please answer the question.
Are you flexible with the days and times required?*
Please answer the question.
Please answer the question.

When would you like the care to commence?*

Day
  • - enter the day -
  • 1
  • 2
  • 3
  • 3
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Please enter your commencement date
Please enter your commencement date
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Please enter your commencement date
Please enter your commencement date
Year
Please enter your commencement date
Please enter your commencement date
Is this position ongoing?*
Please answer the question.
Please answer the question.

If No, possible finish date?

Day
  • - enter the day -
  • 1
  • 2
  • 3
  • 3
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
Field is required!
Field is required!
Month
  • - enter the month -
  • January
  • February
  • March
  • April
  • May
  • June
  • July
  • August
  • September
  • October
  • November
  • December
Field is required!
Field is required!
Year
Field is required!
Field is required!
Will there be any driving required?*
Please answer the question.
Please answer the question.
If yes, is the Worker required to use their own car?
Please answer the question.
Please answer the question.
First Language Spoken at Home*
Please enter your first language.
Please enter your first language.
Other Languages Spoken at Home
Field is required!
Field is required!
Do you have any Communication Requirements?
e.g. non-verbal board etc.
Field is required!
Field is required!
Is there a Behaviour Support Plan in place?*
Please answer the question.
Please answer the question.
If yes, please list the behaviours of concern and the authorised restrictive practices invovlved
Limit of 200 characters
Please limit your answer to 200 characters (including spaces)
Please limit your answer to 200 characters (including spaces)
If yes, please upload a copy
Upload your documents...
Field is required!
Field is required!

If yes, please provider contact details for your Behaviour Support Practitioner

Contact Type
Field is required!
Field is required!
Full Name
Please enter the practitioner's full name.
Please enter the practitioner's full name.
Company Name
Please enter the practitioner's company name.
Please enter the practitioner's company name.
Landline Phone Number
Please include the area code
Field is required!
Field is required!
Email
Please enter the contact's email.
Please enter the contact's email.
Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
  • - select an option -
  • Financial only
  • Medical and Care Related only
  • All of the above
Field is required!
Field is required!

Safety at Home

Do you have any pets?*
Please answer the question.
Please answer the question.
If yes, details of Pets
Please enter details.
Please enter details.
Do you have a swimming pool?*
Please answer the question.
Please answer the question.
Is this is a smoke free home?*
Please answer the question.
Please answer the question.
Are there any environmental hazards in the home we should be aware of? (e.g. renovations, multi-story etc.)*
Please answer the question.
Please answer the question.
If yes, details of Environmental Hazards
Please enter details.
Please enter details.
Will the family accept responsibility for taking all responsible care to protect the staff member form all forms of abuse by family members and guests?*
Please answer the question.
Please answer the question.
Are there any custody orders in place for children?*
Please answer the question.
Please answer the question.
If yes, details of Custody Orders
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).
Are there other people living in the home other than the participant and their family?*
Please answer the question.
Please answer the question.
If yes, details of Other People Living in the Home
Please enter details.
Please enter details.
Is anyone at the property known to be aggressive or violent?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Does anyone at the property have a criminal history?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are you aware of any occupant having an infectious disease?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Is there a history of drugs or alcohol misuse at the property?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are you aware of any firearms stored at the property?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Are there any other factors we should be aware of?*
Please answer the question.
Please answer the question.
If yes, details
Please enter details.
Please enter details.
Please list risk management actions do you currently have in place. What additional risk management actions do you suggest?
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).

Contacts Information

Emergency Contact 1

Full Name*
Please enter your emergency contact's full name.
Please enter your emergency contact's full name.
Mobile Phone Number*
Please enter your emergency contact's phone number.
Please enter your emergency contact's phone number.
Relationship to participant*
Please enter your emergency contact's relationship to you.
Please enter your emergency contact's relationship to you.
Specific Instructions*
Limit of 200 characters
Please enter specific instructions and limit your answer to 200 characters (including spaces).
Please enter specific instructions and limit your answer to 200 characters (including spaces).

Emergency Contact 2

Full Name*
Please enter your emergency contact's full name.
Please enter your emergency contact's full name.
Mobile Phone Number*
Please enter your emergency contact's phone number.
Please enter your emergency contact's phone number.
Relationship to participant*
Please enter your emergency contact's relationship to you.
Please enter your emergency contact's relationship to you.
Specific Instructions*
Limit of 200 characters
Please enter specific instructions and limit your answer to 200 characters (including spaces).
Please enter specific instructions and limit your answer to 200 characters (including spaces).

If you have any other supports, please fill in their contact details

For example: advocate, plan manager, local area coordinator, support coordinator, occupational therapist, physiotherapist, psychologist, or other service provider

Contact 1

Contact Type
  • - select an option -
  • Doctor
  • Advocate
  • Plan Manager
  • Local Area Coordinator
  • Support Coordinator
  • Occupational Therapist
  • Physiotherapist
  • Psychologist
  • Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
  • - select an option -
  • Financial only
  • Medical and Care Related only
  • All of the above
Field is required!
Field is required!

Contact 2

Contact Type
  • - select an option -
  • Doctor
  • Advocate
  • Plan Manager
  • Local Area Coordinator
  • Support Coordinator
  • Occupational Therapist
  • Physiotherapist
  • Psychologist
  • Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
  • - select an option -
  • Financial only
  • Medical and Care Related only
  • All of the above
Field is required!
Field is required!

Contact 3

Contact Type
  • - select an option -
  • Doctor
  • Advocate
  • Plan Manager
  • Local Area Coordinator
  • Support Coordinator
  • Occupational Therapist
  • Physiotherapist
  • Psychologist
  • Other Service Provider
Field is required!
Field is required!
Contact Full Name
Please enter the contact's full name.
Please enter the contact's full name.
Contact's Company Name
Please enter the contact's company name.
Please enter the contact's company name.
Contact Mobile Phone Number
Please enter the contact's mobile phone number.
Please enter the contact's mobile phone number.
Contact Landline Phone Number
Please include the area code
Please enter the contact's landline phone number.
Please enter the contact's landline phone number.
Contact Email
Please enter the contact's email.
Please enter the contact's email.
Contact Postal Address
Please enter the contact's postal address.
Please enter the contact's postal address.
Please indicate the type of information to share with this contact
  • - select an option -
  • Financial only
  • Medical and Care Related only
  • All of the above
Field is required!
Field is required!
Please enter details about the involvement of the participant, family, advocate, other contacts about the decision-making process*
Limit of 200 characters
Please enter details and limit your answer to 200 characters (including spaces).
Please enter details and limit your answer to 200 characters (including spaces).

Confirmation

I would like to opt out of the audit process
All registered NDIS Service Providers need to be audited every 18 months - 3 years. Auditors like to interview participants. Please let us know if you would like to opt out of being contacted by our auditors.
Field is required!
Field is required!
I confirm that all information completed within my Registration form is true and accurate. In order for ALHCA to commence providing service, I also agree to allow ALHCA to share my information with family, guardians, advocates, support workers, support coordinators, local area coordinators, plan managers, relevant health care professionals, other providers, government bodies, welfare supports, referral organisations and other authorised personnel where necessary. We've recorded the level of sharing with your contacts as preciously indicated. You can withdraw this consent at any time however the Agency is required by law in some circumstances to disclose information.*
Public, online or promotional use of your private information will require ALHCA to have you sign a further consent form.
Please confirm.
Please confirm.