South Yarra
Support Services
Client Intake
Takes about 10-15 minutes
Set up for funding ·
What happens next?
Fill out this form
Share details about needs, preferences, and emergency contacts
We'll review and be in touch
Sam will clarify any details and send a Service Agreement within 1-2 business days
Sign and get started
Once you're happy with the Service Agreement, support can begin
Your progress is saved automatically
What's your funding type?
This determines which questions we'll ask
What services will you need?
Select all that apply
Who is completing this form?
This helps us personalise the questions for you
About You
Your Contact Details
Field of
Enter in format: DD/MM/YYYY (e.g., 15/03/1985)
Primary Emergency Contact
Your Phone Number
As the primary emergency contact, what's the best number to reach you on?
A mobile number is preferred so we can reach you quickly
Primary Emergency Contact
Secondary Emergency Contact
(Optional backup contact)
Your Phone Number
As the secondary emergency contact, what's the best number to reach you on?
A mobile number is preferred
Secondary Emergency Contact
(Optional backup contact)
Service Location
You can select multiple locations
Appointed Decision-Maker
Decision-Maker's First Name
Decision-Maker's Surname
Type of Decision-Maker
Decision-maker:
Decision-maker:
Plan Management
Plan Manager Details
We'll send invoices directly to your plan manager.
Appointment Confirmations
Reminders about upcoming support sessions
Invoices
Payment requests for services provided
Consent
Consent of
Review Your Information
Please check everything is correct before submitting
Funding type
Services
Need to change funding type or services?
Who's filling out this form?
Your name
Relationship
Has decision-maker
Decision-maker first name
Decision-maker surname
Decision-maker type
Decision-maker phone
Plan management
Plan manager
Appointment confirmations
Invoices
Form Submitted!
Thank you for completing your intake form. We'll be in touch soon.
Save a copy for your records
Click below to download a PDF of your completed form