Participant First Name *Participant Last Name *Date of birth *NDIS NumberEmail Address *Phone NumberStreet AddressSuburbState/ProvincePost CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweDecision maker / parent / guardian contact detailsAdd if relevant.Emergency Contact NameEmergency Contact PhoneNDIS Support Coordinator NameNDIS Support Coordinator PhoneNDIS Plan start dateNDIS Plan end dateFrequency of sessions requiredAllocated fundsFund Management Type:Plan ManagedSelf-ManagedPlan NomineePlease note we are unable to provide services for NDIA Managed participants.Plan Manager invoice emailFunding Support CategoryAppointment remindersSMSEmailSMS & emailRelationship statusMarriedSingleDe-factoSeperatedDivorcedWidowedIn a relationshipOccupationCourt OrdersPsychiatric medicationReason for the counselling *DepressionWork StressAddiction (drugs/alcohol)SmokingSexual IssuesGrief & lossPanic AttacksPhysical Health IssuesWorkLanguage/Community ParticipationAnxietyStressFamilyParenting issuesFinancial ProblemsObsessive CompulsiveSchizophreniaSelf-care SkillsInattention/Energy/ImpulsivityRelationship IssuesWeight IssuesSleeping IssuesPost Natal DepressionAngerPost-Traumatic StressEating IssuesBehaviours of ConcernSocial RelationshipsCognitive SkillsThis information will help your therapist better understand your needs (check all relevant boxes). *Please provide your practitioner with a copy of the participant’s goals at the end of this form.Please provide the following information about your participant so we can better understand and support their needs.What is the participant’s current disability/diagnosis? *Why is the client seeking psychological services at this point in time? *Please highlight relevant history *Any requirements we should be aware of, for example: male or female therapist, specific days/time for appointments, that may impact allocating a therapist?Are there any behaviours of concern? (please forward a copy of the BSP)Any subjects/events/objects that are triggering for this person?Forensic involvement (current/historic)Participant’s GoalsType your full name below to agree to the disclosure of the details in this form to Living Change Psychology for the purposes of psychological therapy.OR if you are a support cordinator type your name and organisation below to agree that you have gained the written or verbal consent of this participant to disclose the details in this form to Living Change Psychology for the purposes of psychological therapy. SubmitPlease do not fill in this field.