BHC Care - Day Program Enquiry Form

    Please include the details of the participant who would like to Participate.

    Name of Participant*

    Date of Birth

    Gender*

    Current Living Arrangement:


    Contact Details

    Email

    Phone

    Address

    Street Address

    Suburb

    State

    Post Code

    Participant Details

    NDIS Number

    Funding Type

    Plan Manager (If relevant)

    NDIS Plan Start Date

    NDIS Plan End Date

    Day program funding

    No. of Hours intended to visit per Day

    No. of days intended to visit per week

    Assistance Level

    Medication Administration

    Transportation required?. If yes specify details below

    Transportation Details

    Participant’s Area of Interest:

    Any Behavioural Concerns:

    What are your expectations:

    Details of Person Making Referral If same as above, please leave blank.
    (Eg: Support Coordinator).

    First Name

    Last Name

    Phone Number

    Email

    Organization & Position

    Relationship to NDIS participant

    Privacy Statement

    The management of Best Of Home care are committed to ensuring that dealings with Personal Information regarding job seekers, staff, clients and others with whom we deal comply with Australian Privacy laws. In accordance with the Australian Privacy Principles 2014, and the Privacy Act 1988, we will only use your Personal Information for the purpose of assessing your application for employment with us. The information we collect will be handed sensitively and secure with proper regard to privacy.