Request for Home and Living Supports

Request for Home and Living Supports

Home and living supports can assist you to live independently, and improve your living, household and management, social, communication, and behavioural management skills.

Who can complete this form?

Participants or a person acting on their behalf, such as a family member, friend or guardian. In this form we use the term ‘You’ and ‘Your’. This is referring to the NDIS participant.

You can fill out this form electronically or print and complete it using a blue or black pen.

What is this form for?

This form is to let the National Disability Insurance Agency (NDIA) know you need home and living supports in your plan and those supports cannot be met through mainstream, community, informal or other supports. This form can be used to start the process without having to go through a Planner or Local Area Coordinator.

This form helps the NDIA identify home and living supports to meet your needs.

Once the form has been completed and returned:

The NDIA will review your request.
If there is not enough information, we will let you know what we need.
We will let you know the outcome and the next steps.

The NDIS may provide funding for the following home and living supports:

Support so that you can explore different housing options.
Support to help you with developing skills for independence.
Modifications or assistive technology to make your current home more accessible.
Support and help to complete day-to-day tasks.
Specialised supports for care and accommodation for people with very complex needs.

1. Participant details

Full name *

Date of birth *

Current address *

NDIS number *

2. Reason for this request

2.1. What is your main reason for this request?

Mark ‘Yes’ for only the reasons that apply to you.

2.2. Is there another reason for your request?

NoYes

Please briefly describe it below.

3. Current living arrangement

3.1. What is your current living arrangement?

Mark ‘Yes’ only for the arrangement that best describes your situation in the table.

3.2. Do you have a different living arrangement that is not listed above?

NoYes

Please briefly describe it below.

4. Housing and living support goals

4.1. Do you have a housing and living support goal in your NDIS plan?

YesNo

Please write what your goal is below.

4.2. Do you want to add this goal or another housing and living goal to your plan at plan review?

Yes, I want to add the goal I listed in question 4.1 above.Yes, I want to add a different goal to what I listed in question 4.1 above.No, I do not want to add any new goals.

5. Support to help you

5.1. What housing and living supports will best help you to meet your goals?

Mark ‘Yes’ only for the supports that you need.

What housing and living supports do you need?

Yes

Help with maintaining my current home environment

Yes

Help with designing and developing my housing and living supports

Yes

Help to find other people to live with

Yes

Help with modifying my current home

Yes

Help with personal care/daily life tasks at home

Yes

Access to assistive technology and equipment

Yes

Help to find a different home

Yes

6. Your current housing and living situation

6.1. Who do you currently live with?

6.2. How long have you lived in your current arrangement?

6.3. Where did you live before your current arrangement?

Please tell us the address, type of home, and living situation it was below.

6.4. How are you managing at home now?

Is there anything that is unsafe or impacting your daily activities at your current home? Please tell us below.

6.5. What is most important to you for your future living arrangements and support needs?

For example, this may be to have a safe and stable home, or be closer to friends and family, to have space for your children to visit, to be more independent, or to have an accessible home. Please tell us below.

6.6. Do you have any cultural, religious, lifestyle or personal preferences?

NoYes

Please tell us below.

6.7. How would a change to your current living arrangement or supports, improve your overall wellbeing or functioning?

6.8. Do you receive assistance right now from a carer or support person?

NoYes

Please tell us their details are and what they do for you below

Name of carer or support person

Contact phone number

What support do they provide for you?

6.9. Is there anything else you would like to tell us about your current housing and living situation?

NoYes

Please tell us below.

7. How you manage tasks

7.1. How do you manage everyday tasks?

Please tell us your ability with the tasks listed below. Mark only one for each task listed.

8. Your health care needs

8.1. Do you need support with your health care needs?

Please tell us if you have any health care needs listed below. Select ‘Yes’ only for the health care need(s) that apply to you.

9. Assessments and reports

9.1. Have you completed or had a review of any of the plans or programs listed below in the last 12 months?

Select ‘Yes’ only for those that apply to you.

9.2. Have you completed or had a review of a plan or program that was not listed above?

NoYes

Please tell us below.

10. Assistive technology and home modifications

10.1. Do you currently use assistive technology or equipment?

NoYes

Please tell us what it is below.

10.2. Have you had any home modifications done in the past?

NoYes

Please tell us what they were below.

11. Your decision-making

11.1. Do you receive any help with decision-making?

NoYes

Please tell us who helps you below.

Full name

Contact phone number

11.2. What is your relationship with this person?

Please mark the relevant box below.

They are my NDIS nomineeThey are my legally appointed decision makerOther

Please provide us with details of this appointment if not already provided

Please tell us what your relationship with this person is below

11.3. Did you receive any help with completing this form?

Did you receive any help with completing this form?

NoYes, it was the person listed in question 11.1 above.Yes, but it is a different person to the person listed in question 11.1 above.

Full name

Contact phone number

11.4. What is your relationship with this person?

Please mark the relevant option below.

They are my NDIS nomineeThey are my legally appointed decision makerOther

Please provide us with details of this appointment if not already provided

12. Participant consent

This is the consent you provide to the person(s) you have listed in part 11 of this form.

12.1. What information, if any, do you give consent to share with this person?

Please mark the relevant boxes below

A copy of all parts of my current NDIS plan.A copy of my current NDIS plan’s goals and aspirations.A copy of my current NDIS plan’s funding and support.Nil/not applicable.Other

Please specify below

12.2. What actions, if any, do you give consent for this person to do on your behalf?

To request review of your plan, including due to change in circumstances.To request a review of a decision made by the NDIA.To make arrangements for a scheduled plan review.To assist with the submission and implementation of requests for Assistive Technology, Home Modifications, or other specific supports.To manage a complaint made by you.Nil/not applicable.Other

Please specify below

12.3. What is the reason, if any, you are providing this person with consent?

Please mark the relevant boxes below

To complete and sign this Request for Housing and Living Supports.Nil/not applicable.Other

Please specify below

12.4. Is there any other information you consent to share with this person?

NoYes

Please specify what this information is below.

12.5. What length of time, if any, you are providing the consent for?

Please mark only one of the options below.

Please enter date

13. Acknowledgement

13.1. Participant acknowledgement.

Please note: NDIS participants have other options instead of signing here. If you are unable to sign here, you can direct someone aged 18 and over to sign, in the section below called ‘Delegate acknowledgement’. Someone else can also sign the ‘Delegate acknowledgement’ if you have provided consent for them to act on your behalf in part 12 above.

I have been directly involved in this Housing and Living Supports Request and the information recorded in this form reflects my wishes.

Participant's Signature

Draw signature|Type signatureClear

Participant's full name

Date

13.2. Delegate acknowledgement

Please note: This section is only to be completed if the participant is unable to sign above. Instead, their chosen delegate must be aged 18 and over and can sign below.

As the participant’s delegate, I have sought at all times for the participant’s input, decision-making and preferences to be at the centre of this Housing and Living Supports Request. I endorse the information in this form.

Delegate’s full name

Date

Delegate’s signature

Draw signature|Type signatureClear

13.3. What is your relationship with the participant?

Please mark the relevant option below to indicate your relationship to the participant.

I am their NDIS NomineeI am their legally appointed decision makerOther

Please provide us with details of this appointment if not already provided

Please tell us what your relationship to the participant is below

Privacy and your personal information

Collection of your personal information

The National Disability Insurance Agency (NDIA) would like some personal information from you to simplify your engagement with the NDIS. Any personal information you provide to the NDIA is safe under the National Disability Insurance Scheme Act 2013 and the Privacy Act 1988. You can also ask to see what personal information (if any) we hold about you at any time and can seek correction if the information is wrong.

Personal information use and disclosure

The NDIA will use your information to support your involvement in the NDIS.

The NDIA will NOT use any of your personal information for any other purpose, or disclose your personal information to any other organisations or individuals (including any overseas recipients), unless authorised by law or you provide your consent for us to do so.

The NDIA’s privacy policy describes

how we use your personal information
why some personal information may be given to other organisations from time to time
how you can access the personal information we have about you on our system
how you can complain about a privacy breach, and how the NDIA deals with the complaint
how you can get your personal information corrected if it is wrong.

You can read the policy at the www.ndis.gov.au/privacy.

Personal information storage

The NDIA uses an Australian Government computer system to store personal information. System users, other than NDIA staff, may at times be able to see your name when they perform program duties, however they can’t record, use or disclose information, and they will not know if you become an NDIS participant. State or territory government officials may also have personal information access as part of the agreement between governments to assist the states and territories in their NDIS evaluation.

Save and Complete Later