At Etan Health Care, we simplify the process for you to access our services. We require certain information from you to begin and guarantee a seamless onboarding experience.

PARTICIPANT DETAILS *

First Name

Last Name

Gender *

Date of Birth:

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number *

(###)

###

####

Email Address *

Preferred method of communication *

NDIS Number

NDIS Funding Type:

Self Managed

Plan Managed

NDIS Managed

PERSONAL DETAILS

Living Situation

Own home (living alone)

Own home (living with family)

Living in supported accommodation

Temporary (relatives, friends or other)

At risk

Homeless

Other

Primary Formal Diagnosis:

Secondary Formal Diagnosis:

REPRESENTATIVE OR EMERGENCY CONTACT DETAILS

Contact 1:

Advocate

Guardian

Parent

Support Person

Emergency Contact

Plan Nominee

Other

Name

Relationship to Client:

Contact Number:

(###)

###

####

What Etan Health Care services do you require?

In-Home and Community Supports

Daily personal Activities

Assistance with Travel/Transport Arrangements

Innovative Community Participation

Development of Daily Living and Life Skills

Household Tasks

Participation in Community, Social and Civic Activities

Supported Independent Living/Respite Care/Group

Assistance with Daily Life Tasks in a Group or Shared Living Arrangement

Group and Centre Based Activities

CONSENT AND ACKNOWLEDGEMENT

By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.

Thank you!

Get in touch.

0424 694 807
(After-hours number)
08 6444 7930 (Landline number)

08 6444 790830
info@etanhealthcare.com.au
2232B Albany Hwy, Gosnells WA 6110

Email Address

We respect your privacy.

Thank you!