Name *

First Name

Last Name

Phone

(###)

###

####

Are you an NDIS Participant or likely to be eligible for the NDIS? *

Yes

No

Are you aged 65 years or over? *

Yes

No

Have a significant and permanent disability that: *

Please select one or multiple boxes

Affects your ability to take part in everyday activities, and

Means you need specialist housing features to assist you with daily life.

None of the above

Do you need help from another person to transfer or move around your home safely? *

Yes

No

Do you need help from another person to support you with your self-care tasks? (Showering, toileting, dressing, eating, or drinking, taking medications?) *

Yes

No

Do you need help from another person for self-management tasks? (Housework, following routines, maintaining relationships, managing behaviours)? *

Yes

No

How many hours of support do you require each day with the tasks you have indicated you need support with? (Including paid and unpaid support) *

Please choose one

5 hours or less

6 hours or more

None of the above

Would the features of specialised housing assist you to achieve your goals and build your skills and capacity? (e.g. design features like ceiling hoists, reinforced walls, and breakout rooms) *

Yes

No

To be eligible for specialist disability accommodation (SDA) funding under the National Disability Insurance Scheme (NDIS), you must meet certain requirements. *

Please select one or multiple boxes

have high support needs arising from your disability

require housing that is specifically designed or adapted to meet your needs

be under the age of 65 years

be an Australian citizen or permanent resident, or hold a protected special category visa

have permanent residency in Australia

be living in Australia when you first apply for NDIS funding

None of the the above