Home How to get support Enquire about supportsEnquire about supportsStep 1 of 30%Thank you for choosing us! We need a bit of information before we can get started.This form will take about 5 – 10 minutes to complete. We will contact you after you have completed this form to discuss services.I am completing this for: * Required Myself Someone else (child / someone I care for / I am referring someone else) Details about the person making the enquiryFirst name * RequiredLast name * RequiredMobile * RequiredEmail address * Required Relationship to participant * Required Parent Carer Guardian Spouse Health Professional Support Coordinator Local Area Coordinator Other OtherDetails about the participantFirst name * RequiredLast name * RequiredPreferred GenderDate of birth * Required Day Month YearSuburb and post code * RequiredMobile * RequiredEmail address Diagnosis or condition * RequiredSecondary diagnosis or current health concernsContact details * Required Same as the referrer Other Mobile * RequiredEmail address Who would you like us to contact? * Required Enquirer Participant Some more helpful information for us to knowHow will your therapy be funded? * Required NDIS Private GP Care Plan What is your NDIS number?What are your NDIS plan dates?What are your NDIS plan goals?Please share a copy of your NDIS plan to better help us support you.Accepted file types: pdf, doc, docx, Max. file size: 150 MB.What supports are required?Please carefully select the supports that you require or that are documented in the NDIS plan. If you are unsure, please select ‘other’ and we will contact you to discuss further.What supports are required? * Required Occupational Therapy Physiotherapy Exercise Physiology Speech Pathology Psychology Positive Behaviour Support Functional Capacity Assessment (FCA) Assistive Technology / Equipment Home Modifications Please select which supports you are seeking belowAdditional informationCan you describe the support you are seeking or your needs? * RequiredPreferred location you wish to receive supports (Suburb or school name)? * RequiredAs a mobile therapy provider, Kern provides supports where you need it most, in the home, school or community setting across the southern Perth, Bertram and Mandurah region. We also offer clinic-based support within our Bertram and Mandurah clinic.Where did you hear about Kern? Google Kern Staff NDIS Social Media Support Coordinator Capacity Newsletter Traditional Marketing (brochure, newspaper) Website Word of Mouth Other Δ
