Accommodation & Service Options Form

I am a

NDIS Participant

Family Member

Assigned Guardian

Friend

Support Coordinator

Other

Full name of the person filling out this enquiry*

Phone Number*

Email*

Preferred contact method

Phone

Please indicate the accommodation option(s) you are enquiring for*

Respite

Short Term Accommodation

Medium Term Accommodation

Long Term Accommodation

Supported Independent Living

Other (Please specify)

Other*

Indicate service option required

SIL

Respite

In home supports

Capacity Building

Other

Participant Details

To help us assess your enquiry, please provide details of the person requiring supports from BoraCare.

Participant Name*

Participant Gender

Participant Age

Accommodation/ Service Location Preference

Northern Adelaide Metro

Western Adelaide Metro

Eastern Adelaide Metro

Southern Adelaide Metro

Regional (Whyalla)

Other

Other*

Please indicate any individual support requirements

Cultural needs

Sensory needs

Mobility needs

Other

Other*

Consent*

I acknowledge and consent to BoraCare collecting and securely storing the information I have provided. I understand this information will be safely and securely stored in accordance with the Australian Privacy Principles, and BoraCare’s Privacy and Confidentiality Policy.

This field is for validation purposes and should be left unchanged.

Participant Details

We support you to fully participate in the community and reach your full potential.