Booking Enquiry Are you a Family member, carer, support worker or friend completing this form?(Required)SelectYes (please provide details in the next section)NDIS Participant DetailsName(Required) First Last Phone(Required)Email(Required) Date of Birth Month Day Year Primary Diagnosis Address(Required) Street Address City State / Province / Region ZIP / Postal Code Do you live with a full-time carer?(Required)YesNoIs it written into your plan? Yes Do you have a support worker at home?(Required)YesNoHow many support hours per day/week?Do you have specific STA activity-based goals built into your NDIS Plan?(Required)YesNoWas STA declined as a support in your NDIS Plan?(Required)SelectYesNoEither at the planning meeting or advised by an LAC or NDIS Delegate?NDIS Plan DetailsIs your NDIS Plan managed?(Required)SelectSelf ManagedPlan Managed (please enter your Plan Manager's email in the next section if you have one)Plan Manager email(Required) Do you have a Support Coordinator?(Required)Yes (if yes, please enter details in the next section if you have one)NoSupport Coordinator Name(Required) First Last Support Coordinator email(Required) Support Coordinator Phone(Required) HiddenDo you wish for your Support Coordinator to be included in your enquiry and planning process? Yes No Comment(Required)Upload Your Self Managed Fund DocumentsUpload NDIS Plan(Required) Drop files here or Select files Max. file size: 20 MB. We require a screen shot or PDF of your Funded Supports Page which contains the participant plan dates - *start and review date - and the core budget support categories - *which evidences if self-managed & also the funding allocation ($ value) over the life of the plan.Upload Evidence of Funds(Required) Drop files here or Select files Max. file size: 20 MB, Max. files: 3. Please provide a screenshot from your NDIS portal of the current' real time' fundingHave you reserved your STA accommodation?(Required) Yes No HiddenIf proceeding with this STA/Respite request, do you wish Habitability to transfer your accommodation costs to your nominated account for 'self - pay' on check-in? Yes No Do you wish to bypass our STA Quote and go straight to our Service Agreement?(Required) Yes No *By requesting the YES option - this does not constitute your approval and you are not obligated (to proceed with your STA request) - until you have consented to the term & conditions contained within our service agreement by way of your digital signature. Support RequirementsHiddenPaid support or solo?SelectPaid supportTravelling alonePlease note, if you are planning to travel alone the NDIA require evidence that independent travel will be safe and appropriateHiddenWill you be bringing a support worker?Please note, if you are planning to travel alone the NDIA require evidence that independent travel will be safe and appropriateYesNoSupport Hours(Required)*Min – 2** per day – can be spread over the course of the respite | If you answer YES Evidence of this will be required.YesNoHiddenThe NDIS require supporting evidence to fund independent travel Yes Are you happy to proceed with this in mind? HiddenDo you require Habitability to provide a support worker? HiddenHow many hours per day Male or female/or no preference(Required) Contact Person to Discuss Your STAContact person to discuss building your STA(Required) Who should we contact to discuss building your STA e.g. with you, a representative or a plan manager / support coordinator?Contact person name(Required) First Last Contact PhonePlease enter If not supplied already in other section of the form.Contact Email Enter if not already supplied in this form.Person Responsible for Signing STA Service AgreementRole or Relationship?(Required)Self ManagedPlan ManagerSupport CoordinatorRepresentativeMy Contact for this enquiryAnd their Email?(Required) Enter the person or role responsible for signing the agreement, or unsure if not known at this time.STA Booking DetailsPlease list the Name of location of the STA Accommodation you would like to stay in from our website. *If you are unsure at this time of your STA Accommodation preference, please write- UNSURE *(Required) STA Respite Check in date(Required) MM slash DD slash YYYY STA Respite Check out date(Required) MM slash DD slash YYYY HiddenNumber of bedrooms (depending on if your carer or support worker is attending the STA with you)SelectOneTwoOther (please specify)HiddenOther Room Requirements(Required) Standard Room Accessible Room Additional requirements(Required) Car Transfer Specialized Equipment Wheelchair accessible room Walk-in shower None of the above Please specify requirements(Required) Write N/A if not applicableHiddenDaily STA Provision The quotes for meals and activities are negotiable and optional. Read the STA FAQ's on our website re the prepaid vouchers https://habitability.com.au/faq/Requested STA Daily Provision(Required)Habitability can provide up to $200 per day for food & special dietary needs breakfast, lunch & dinner.$0 - $100$0 - $200 Once your STA Booking Enquiry Form is submitted, our STA Intake & Assessment Coordinator will contact you within 24-48 hours. Should we require additional information or clarification prior to sending you a Provisional STA Quote, this will be discussed at the time of contact and is an opportunity to discuss your specific requirements and customise your individual STA requirements. Prior to approving your Provisional STA Quote, please seek confirmation from your Plan Manager and/or Support Coordinator (where applicable). Upon approval of your STA Quote, we will formalize our NDIS Service Agreement (SA) within 24-48 hours, which will be sent to you for approval within 48 hours. Once your SA is signed, our Habitability STA Coordinator will be assigned to you, who will be on hand to assist you through to completion of your STA. Please note the terms and condition outlined within your SA, including STA Cancellation Fees as per the NDIS Guidelines. Please note also the terms and conditions outlined within your SA, pertaining to our STA Accommodation Third Party Cancellation Policy, which sits outside of the NDIS Guidelines. I acknowledge I have read the above additional STA Respite information(Required) I acknowledge- I have read the above additional STA Respite information CAPTCHA
