Service capacity notification

1. Service provider group:
2. Provider (outlet) number:
3. Contact:
4. Telephone:
5. Email:

1. Notification Reasons:

   This field is required.

   Client passed away (date required)Please specify:

   Client moves interstate

   Client support ceasedPlease specify:

   Client support needs reducedPlease specify:

   New capacity available as a result of changes to service model, cost, review of capacity, etc.Please specify:

   OtherPlease specify:

1. Surname:
2. First name:
3. Date of birth:
4. BIS ID (if known):

1. Service description:SelectAccommodation SupportCommunity SupportCommunity AccessRespite
2. NMDS service type:Select1.011.0141.021.0241.0411.0421.0441.051.061.071.0822.012.022.0212.032.042.052.0623.013.023.044.014.0214.0224.0314.0324.044.0514.052
3. Support location:

   Centre based

   Community

   OtherPlease specify:

4. If 1.01-1.04 accommodation support (mandatory if accomodation support)

5. Overnight support:SelectAwake supportSleepoverNone
6. Average spread of active support hours per day:Selectless than 8 hours9-15 hours16 hours24 hours
7. Status of Capacity:SelectPermanentTemporary
8. Available from date:
9. Available to date (mandatory if temporary service):
10. Support Model:

    This field is required.

    one-on-one support

    shared / group

(Specific to this capacity notification only)

1. Primary Disability Target Group:IntellectualSpecific Learning / ADDAutismPhysicalAcquired Brain InjuryNeurologicalVisionHearingSpeechPsychiatricDevelopment DelayNo specific requirements
2. Age Groups:

   This field is required.

   Age range preferredPlease specify:

   Age range requiredPlease specify:

   No specific requirements
3. Gender:

   This field is required.

   Male preferred

   Male required

   Female preferred

   Female required

   No specific requirements
4. Cultural Groups:

   This field is required.

   Preffered cultural groupPlease specify:

   Required cultural groupPlease specify:

   No specific requirements

5. Support can be provided for a person with a disability who has:

6. Complex health needs:

   Yes

   No
7. Behaviour support needs:

   Yes

   No
8. Mobility support needs:

   Yes

   No
9. Other:
10. Geographical area covered by the capacity (if applicable):

1. Notes: