Participant Consent Form

Referral to SD Case Management Pty Ltd

This form confirms that the participant has agreed to be referred to SD Case Management for plan management.

Participant Details

Please provide the participant's information

Participant's Full Name *

Date of Birth *

Gender *

Female

Male

Non-binary

Other

NDIS Number *

Home Phone

Mobile Phone *

Email Address *

Language Spoken at Home *

Interpreter Required

Preferred Communication Method *

Post

Phone

Identifies as Aboriginal and Torres Strait Islander

Residential Address *

Postal Address (if different from above)

Person Assisting with this Consent (Optional)

Only complete this section if someone else is supporting the participant (e.g. support coordinator, provider, family member)

Someone is assisting with this consent form

Acknowledgment

Please review the following statements

I give permission for SD Case Management to receive my NDIS and personal information as part of this referral
I understand that SD Case Management may contact me or my representative to discuss plan management and/or bookkeeping services
I understand this referral does not lock me into any contract, and I am free to withdraw at any time
I consent to SD Case Management managing invoices, and I accept the 3-day auto-approval period (if applicable)
I acknowledge that a Service Agreement will be shared with me upon sign-up