SchemeWise Service Request Form

SchemeWise requires certain information about the participant and referrer, as well as the participant's NDIS plan (or goals for therapy services), in order to advance a service request. We must be able to verify that there are sufficient funds to provide the service and reserve such right in order to reduce the potential for a debt arising to an NDIS participant. We understand that there may be finite funds available, please work with us and be honest about what is possible - likewise we will do our best to help. We may not be able to advance a service if we think it may cause harm or not otherwise be beneficial in our professional opinion.

NOTE: Referrers should reach out to us on 1300 785 567 or via email and discuss a potential service firstly, as 'unannounced' service requests will NOT be further actioned or responded.

All NDIS services must provide at least a progress report, and NDIS goals are required for this purpose. SchemeWise will secondarily use same in service planning with the participant.

Please look over the information SchemeWise requires (below) and ensure that all the information is available to you BEFORE you start - we've tried to ensure our service needs are simple and straight forward, while also making it as convenient for you as possible. Some information is essential for us to put in place a service agreement, without which, there will be additional delays. Fields marked 'required' must be populated with information, or this form will NOT allow you to submit.

Thanks for your referral to SchemeWise.

Participant's First and Last Name (required)

Participant's Address - include unit, street, suburb, state, postcode (required)

Participant's Email (required)

Participant's Phone/Mobile (required)

First and Last Name of person filling out this form (required)

Role of this person (required)
Not applicableSupport CoordinatorHealth / Allied-health ProviderNDIS ProviderCommunity Service AgencyPublic GuardianNDIS/LAC Planner

Your Email (required)

Your Phone/Mobile (required)

Have you obtained consent to make this referral?
YESNO

Person's name who consented & their role (e.g. Joe Bloggs - Power-Attorney/Legal Guardian/Plan nominee/Parent, or state 'Participant')

Service required (ONLY CHOOSE ONE)
Support CoordinationCase Management & PlanningRehabilitation SupportCommunity NursingNurse Assessment/TrainingOccupational TherapyService Incident/Crisis DebriefingPsychosocial Recovery Coaching

Source funds for the service within NDIS plan
Funds sourceSupport CoordinationImproved Daily Living (CB Daily)Core Funding (Daily activities)Private Service

Funds management for this service? NOTE: We no longer provide support for NDIA-managed services (required)
Please chooseNDIS Plan-managedNDIS Self-managedPrivately funded

Frequency of service being requested and length of intended service (e.g. weekly, fortnightly, monthly for length - 3mths, 6mths, 12mths, etc?)

Participant's NDIS Plan Start Date (required)

Participant's NDIS Plan End Date (required)

Participant's NDIS Number (required)

Participant's date of birth (required)

Participant's NDIS Goals relevant to the service (required)

Participant's NDIS plan manager name (leave blank if not used)

Plan Manager's Email (must provide if used - leave blank otherwise)

Plan Manager Phone/Mobile (must provide if used - leave blank otherwise)

Plan manager location in town/suburb ACT/NSW. E.g. Albury NSW or Braddon ACT (must provide if used - leave blank otherwise)

Disability/Diagnosis and/or brief background information on why the service is sought (include budget for the service, if known, to assist service design)?

Are there any risks or limitations we need to know about in providing this service? (e.g. preferred times of contact or service, short-term memory issues, pet inside, behaviours like anger/aggression, vaccination status or related risks/precautions, environmental issues at location, etc)

Consent and Privacy Statement: By clicking the 'Submit Service Request' button below you are agreeing to provide this information to SchemeWise and you also agree we may hold this information on our systems for the purposes of discussing and advising about the service request and our services we think may be of interest. You also agree you have discussed and obtained agreement from the NDIS participant to make this request (if relevant). We take privacy seriously. For your assurance, the information provided is held internally in strictest confidence and is not sold, provided or disclosed to any other party.