Splana NDIS Registration Form NDIS Provider Registration – Client Intake Form | Splana S SPLANA NDIS Provider Registration Assistance Service Client Intake Form Welcome to Splana! This comprehensive intake form helps us understand your business and registration needs, allowing us to provide tailored support for your NDIS provider journey. All information is treated confidentially. 📋 SECTION 1: BUSINESS DETAILS Business Structure * Sole Trader Partnership Company Trust Not-for-Profit Legal Business Name * Trading Name (if different) ABN * ACN (if applicable) Business Address * Suburb * State * Select State NSW VIC QLD WA SA TAS ACT NT Postcode * 👤 SECTION 2: PRIMARY CONTACT DETAILS Title * Select Title Mr Mrs Ms Miss Dr Prof First Name * Last Name * Position/Role * Date of Birth * Email Address * Phone Number * Mobile Number 👥 SECTION 3: ADDITIONAL DIRECTORS/KEY PERSONNEL Please list all directors, partners, or key management personnel involved in the business. Additional Personnel Details 🏢 SECTION 4: NDIS REGISTRATION INFORMATION Current NDIS Status * New to NDIS (Never registered) Existing Provider (Seeking additional groups) Registration Renewal Registration Groups Required * General Registration Groups 0101 – Accommodation/Tenancy Assistance 0102 – Assistance to Access and Maintain Employment or Higher Education 0104 – High Intensity Daily Personal Activities 0106 – Assistance in Coordinating or Managing Life Stages, Transitions and Supports 0107 – Daily Personal Activities 0108 – Assistance with Travel/Transport Arrangements 0115 – Assistance with Daily Life Tasks in a Group or Shared Living Arrangement 0116 – Innovative Community Participation 0117 – Development of Daily Living and Life Skills 0120 – Household Tasks 0125 – Participation in Community, Social and Civic Activities 0127 – Management of Funding for Supports in Participants’ Plans 0129 – Specialised Driver Training 0130 – Assistance Animals 0131 – Specialised Disability Accommodation 0133 – Specialised Supported Employment 0136 – Group and Centre Based Activities Professional Registration Groups 0110 – Specialist Positive Behaviour Support 0114 – Community Nursing Care 0118 – Early Intervention Supports for Early Childhood 0119 – Specialised Hearing Services 0121 – Interpreting and Translation 0126 – Exercise Physiology and Personal Training 0128 – Therapeutic Supports 0132 – Specialised Support Coordination 0134 – Hearing Services 0135 – Customised Prosthetics Home and Vehicle Modification Registration Groups 0109 – Vehicle Modifications 0111 – Home Modifications Assistive Technology and Equipment Registration Groups 0103 – Assistive Products for Personal Care and Safety 0105 – Personal Mobility Equipment 0112 – Assistive Equipment for Recreation 0113 – Vision Equipment 0122 – Hearing Equipment 0123 – Assistive Products for Household Tasks 0124 – Communication and Information Equipment Service Delivery Areas * ✅ SECTION 5: BUSINESS READINESS Do you have the following in place? Public Liability Insurance Professional Indemnity Insurance Workers Compensation Policies & Procedures Business Plan Financial Management Systems Quality Management Systems Staff Screening Processes Current Team Size Select Team Size Just me 2-5 employees 6-10 employees 11-20 employees 21-50 employees 50+ employees Annual Revenue (if existing business) Select Revenue Range Start-up (no revenue yet) $0 – $100,000 $100,001 – $250,000 $250,001 – $500,000 $500,001 – $1M Over $1M Website (if applicable) 🎯 SECTION 6: SUPPORT REQUIRED What assistance do you need from Splana? * Complete Registration Support Application Review & Submission Policy & Procedure Development Quality & Compliance Support Verification Preparation Business Systems Setup Staff Training & Development Ongoing Compliance Support Desired Registration Timeline * Select Timeline ASAP (Within 1 month) 1-3 months 3-6 months 6+ months Current Challenges or Concerns Additional Information 📣 SECTION 7: HOW DID YOU HEAR ABOUT US? Referral Source Google Search Social Media Professional Referral NDIS Event/Conference Other Referral Details (if applicable) Privacy Notice: Splana respects your privacy and will handle all information in accordance with Australian Privacy Principles. Your information will only be used to provide NDIS registration assistance and related services. I consent to Splana contacting me regarding my NDIS registration enquiry * I would like to receive Splana’s NDIS provider updates and resources Submit Registration Enquiry Form secured by Web3Forms
