Eligibility Form

Eligibility Form

Please complete this form to determine your eligibility for receiving services from Infinity and Beyond Care. Your responses will remain confidential and will be used solely for assessing your eligibility.

Please enable JavaScript in your browser to complete this form.
Gender
Address

1. Are you impacted by any disability?

Please indicate whether you have a disability that impacts your daily life and requires support.

2. NDIS Participant Status:

Are you currently an NDIS participant or have you applied for the NDIS?

3. NDIS Number (if applicable):

4. Support Category:

Please indicate the main category of support you are seeking from Infinity and Beyond Care.

5. Funding Plan:

Do you have an NDIS funding plan in place?

6. Do you have an NDIS funding plan in place?

7. Medical and Health Information:

8. Additional Information:

9. Permission to Contact NDIS:

Do you grant us permission to contact the NDIS on your behalf to verify your eligibility and funding status?

10. Are you of Aboriginal and/or Torres Strait Islander origin?

Are you of Aboriginal and/or Torres Strait Islander origin?

11. Preferred Contact Method:

How would you prefer to be contacted regarding your eligibility assessment?

12. Consent to Data Collection:

By submitting this form, you consent to the collection and use of your personal information for the purpose of assessing your eligibility and providing relevant services.
Click or drag a file to this area to upload.

13. Signature:

Scroll to Top