Key Word Sign Australia Intake Form

Details of person making the request

Date(Required)

Contact Name(Required)

First Last

Relationship to person (or position)(Required)

Organisation (if applicable)

Phone(Required)

Email(Required)

Details of person requiring the product or service (the NDIS participant)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Male

Female

Non-binary / Other

Date of Birth(Required)

Primary Diagnosis(Required)

Click to add additional lines.

Shop items / services requested(Required)

Please list each item / service requested. Note that there is a minimum purchase value of $75.00. Lower value requests can be self managed by purchasing items directly through our online store.

National Disability Insurance Scheme (NDIS) details

NDIS Participant Number(Required)

NDIS Plan Start Date(Required)

NDIS Plan End Date(Required)

Plan goal that request relates to(Required)

Outcome the person hopes to achieve(Required)

Support Area (If you are unsure what area your supports are in, check your plan)(Required)

Core Support budget (for resources)

Assistive Technology budget (for resources)

Capacity Building Support budget (for training)

How will the supports be paid for?(Required)

NDIS will pay Key Word Sign Australia directly for these supports

NDIS will pay my plan management agency directly for these supports

Name of Plan Manager / Management Agency (if applicable)

First Last

Further details of Plan Manager / Management Agency (if applicable)

Please enter relevant contact details (Phone, Email, Address)

Terms and Conditions

Payment terms are strictly seven days.

Cost

The final cost of products and services provided are subject to confirmation of materials, design and content specifications. If the customisations exceed this estimated cost, a revised quote will be provided.

Disclaimer

Key Word Sign Australia, as a business unit of Scope (Aust) Ltd provides the services and products on an “as is” basis on the information provided by you. Except to the extent permitted by law, Scope makes no warranties as to the accuracy, reliability or guarantee merchantability of the products provided. Scope accepts no responsibility or liability for any loss or damage resulting from use and reliance of the services or products. The individual using the services and products is responsible for seeking independent advice to ensure that the services and products are fit for their intended use.