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Slacks Creek
Eight Mile Plains
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Meet The Team
Slacks Creek
Eight Mile Plains
Operations Team
FAQ
NDIS Referral
Relationship To Participant
Participant
Support Coordinator or LAC
Family Member or Nominee
Other
Referrer Given Name
Referrer Surname
Referrer Phone Number
Referrer Email
Participant Given Name
Participant Surname
Participant Date of Birth
Participant NDIS #
Participant Phone Number
Participant Email
Participant Primary Disability
Participant Address
Participant Address Line 2
Participant City
Participant State
Participant Postcode
Which Clinic Would You Prefer To Attend
Eight Mile Plains
Slacks Creek
Is A Home Visit Preferred or Required?
No
Yes
The Following Are Questions About The Participant And The Property Where Services Will Be Completed (Please Tick All That Apply).
N/A
This environment is not a safe space to provide an exercise or dietary intervention
There are dangerous dogs on the property
There is a history of drugs and/or alcohol abuse
The participant smokes tobacco inside the residence
The participant has a history of aggression (verbal and/or physical)
There are triggers for aggression that we should be aware of
Triggers for anxiety or stress should be addressed with the clinician prior to initial assessment
There is no private or free street parking available
It is inappropriate/unsafe for clinicians to attend this residence alone
The participant or person(s) living on the premises have been in the criminal justice system
Participant's Available Days And times To Attend Appointments
Would you like to provide Champion Health with any personal culturally relevant information? This may be related to your culture, values or beliefs. If not now, please feel free to provide this information to us at any time.
Which Services Do You Require? (Please Tick All That Apply).
Physiotherapy
Exercise Physiology
Dietetics
Diabetes Education
Massage Therapy
Psychology
Plan End Date
How Is The Participant's NDIS Plan Funding Managed?
Agency Managed
Plan Managed
Self Managed
Is This An Emergency?
Are Services Transitioning From Another Service Provider?
No
Yes
Do You Give Permission For A Handover?
Yes
No
If Yes
Does The Participant Have A Support Coordinator or LAC?
No
Yes
If Yes
Who Will Be Signing The Service Agreement?
Participant
Participant's Nominee
Participant's Public Guardian
If Nominee Or Public Guardian
Who Should Champion Health Contact To Book Appiontments?
Referrer
Participant
Support Coordinator
Other
Please Upload Any Relevant Participiant's NDIS Goals And Any Other Documents. (Max File Size 128mb. Max Files 10. Allowed File Types jpg, pdf, doc, docx, zip)
Champion Health is always expanding and using our networks . What other services are you struggling to access?
Submit
Eight Mile Plains
(07) 3709 5554
EightMilePlains@champhealth.com.au
Building 2, Level 1/7 Brandl Street
Slacks Creek
(07) 3299 2794
SlacksCreek@champhealth.com.au
3409 Pacific Highway
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