Client Registration Form - Unity Care Services Australia

Getting started with UCSA.

NDIS Participants

To get started with UCSA, we need a couple of things:

Your NDIS plan – if you have a copy, please upload it down below. Otherwise download it from your MyPlace account on MyGov or take a photo of it and email it to info@UCSAustralia.com

2. Fill out the client registration form below

If you would like to talk to someone in person, call UCSA on 0455 333 118

Facilities – Please email enquiries@UCSAustralia.com with staffing requirements (Facility contact person, facility details, number of staff and qualifications required and duration required).

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Number

NDIS PLAN

NDIS Number

Plan Start

Plan End

Is this your first NDIS Plan?

REPRESENTATIVE

Does the participant have a representative? (If applicable)

Contact number of representative

Representative's postal address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

SUPPORT COORDINATOR

Do you have a support coordinator

Request Details

Date of Request

Referrer Contact Name

Name of Organisation / Business

I agree the information I have provided is true and correct (please check box)

Please upload a copy of your NDIS Plan here

Click or drag files to this area to upload. You can upload up to 2 files.