Applicants Details Lets find out more about you First Name* Last Name* Contact Number* Email* Current Address*Date of Birth* MM slash DD slash YYYY Preferred SDA Development*Select an optionEaton on UnionStella on HannellWhat is your primary disability?* Acquired Brain Injury Spinal Cord Injury Cerebral Palsy Progressive Neurological Condition (such as multiple sclerosis, Motor Neuron Disease, Huntingtons) Other – Please Provide Details Do you have a secondary disability or multiple disabilities?Where do you currently live?* With family With friends Alone in your home (privately purchased) Alone in home (rental) Nursing home/residential aged care (RAC) Group home shared supported accommodation Boarding house/Supported Residential Services (SRS) Hospital Other Please provide details*Who is completing this form?* Me (applicant) Family/Friend Organisation Other Please provide details*The details of the person filling this form for youName* Relationship to applicant* Organisation* Contact phone number* Email address* How would you like us to communicate with you?* Contact me (applicant) Contact someone else details below: please provide your preferred contact method, phone, email or by appointment.*Their name* Relationship to applicant* Organisation (if applicable) Contact phone number* Email address* Other Details* What is your current NDIS Status? NDIS participant with current plan NDIS participant waiting for plan approval NDIS participant waiting for planning meeting Waiting for NDIS eligibility approval Waiting for NDIS to come to my area Not NDIS Eligible NDIS NUMBER What housing supports are currently in your plan?* Specialist Disability Accommodation (SDA) approval If you have SDA approval, what ‘design category’ do you have? Exploring housing options and seeking SDA approval with; * High Physical Support Robust Fully Accessible Improved Livability Basic Not sure Professional Support Coordinator and/or an Allied Health Professional Goal to move out to live independently and plan review in place None – Please refer me to an SDA Specialist How are your supports currently funded?* NDIS State Government Disability (DHHS) Department of Veterans Affairs Public Trustee Compensation scheme – (ie WorkCover) I have no funding support Other Please provide details*What sorts of technology and home design would you find to benefit you and support you to live more independently? Emergency communications system Home automation to assist you with opening doors, blinds etc Widened doorframes, spacious rooms Adjusted bench heights Bathroom modifications Ceiling hoist Please describe in detail any home modifications you think you may need Please describe in detail any home modifications you think you may need*Do you agree to our 10:1 model, which includes the following Some of my NDIS funding will be used to pay for my need for an on-site staff member as a back-up to my other (individual, 1:1) supports Some of my NDIS funding will be used to pay for coordination of this back-up support The back-up support and coordination will be provided by a service provider who will be initially appointed by InSitu Housing. Are you comfortable for us to share your application/contact details with the appointed service Provider? * Yes No Finally, what is your preferred apartment configuration?* 1 Bedroom Apartment 2 Bedroom Apartment (second bedroom not SDA compliant)