Full Name *
Relationship to Participant * Select RelationshipParent / GuardianSupport CoordinatorPlan NomineeParticipantOther
Phone Number *
Email Address *
Preferred Contact Method Select Contact MethodPhoneEmailText Message
Participant Full Name *
Participant Age
Participant's Suburb / Town
Is the Participant an NDIS Participant? Select OptionYesNoApplying / Unsure
NDIS Plan Type Select Plan TypeSelf-managedPlan-managedNDIA-managedUnsure
NDIS Number (Optional)
Does the Participant have a Support Coordinator? Select OptionYesNoUnsure
Support Coordinator Name
Organisation
Phone
Email
What are you interested in? Social Group ActivitiesLife Skills ProgramCafé Skills / Hospitality SkillsCommunity ParticipationCooking / Food Preparation SkillsCreative ActivitiesMovement / Fitness ActivitiesSensory-Friendly SessionsSchool Holiday ActivitiesWeekend or Evening Social EventsNot Sure Yet - I Would Like to Discuss
What would you like the participant to gain from Lara's Clubhouse?
What type of environment helps them feel comfortable and included?
What skills would they like to build?
What are the participant's hobbies or interests?
What level of support does the participant usually require? Select Support LevelLow SupportModerate SupportHigh Support1:1 SupportUnsure
Does the participant need assistance with personal care? Select OptionYesNoSometimes
Does the participant need support with communication? Select OptionYesNoSometimes
Does the participant use any communication tools? VisualsCommunication DeviceKey Word SignsOtherNo
Does the participant have any allergies or dietary requirements we should know about?
Are there any known risks we should be aware of to help keep the participant and others safe?
Are there any health, mobility, sensory or behavioural support needs we should be aware of before arranging a meet and greet?
Preferred Days MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Time MorningDay Program HoursAfternoonEveningSchool Holidays
How often are you interested in attending? Select FrequencyWeeklyFortnightlyMonthlySchool Holidays OnlyNot Sure Yet
How did you hear about Lara's Clubhouse? FacebookInstagramWebsiteSupport CoordinatorTherapistFriend / FamilyCommunity EventOther
I consent to Lara's Clubhouse contacting me about this enquiry.
I understand this form is an expression of interest and does not guarantee a placement.
I understand Lara's Clubhouse may request further information before confirming suitability, support needs and availability.
