Wellness Package Enquiry Form First Name Last Name Date Of Birth Phone Number Email Post Code How is your plan managed? Please select an option below Self Plan Agency Plan Manager NDIS No. Preferred start date for respite Preferred end date for respite Please provide detailed information about your NDIS Diagnosis Please list your support requirements. Include: Personal Care, Mobility Limitations, Accessible Aids required, General Support Preferences. Support Coordinator Name Support Coordinator Company Name Support Coordinator Number Support Coordinator Email Support Worker Who is coming with you for respite? Please select an option below I'm coming on my own With my own support worker With family or a friend Do you have any other details? Please provide your transport requirements Please select an option below I will have my own car I would like a rental car I would like a support worker to drive me where I want to go I don't need a car. I'm happy to be central and walk Do you have any specific requirements for your accommodation i.e wheelchair accessible, specific accessible aids. Please list any specifics about your accommodation location preferences. i.e. I'd like to be near the beach. I'd like to be in town. I'd like to be somewhere quiet and away from people. etc What is your ultimate goal from your respite Please list any interests and activities that you would like to do during your respite Anything else we need to know to support you during your respite? submit
