Plan Management Intake Form

Welcome to our Plan Management Intake Form page. This is where your journey with iConnect Plan Management begins. We’ve designed this form to make it easy for you to get started on your NDIS plan management journey with us. By providing us with some essential information, you’re taking the first step toward having a dedicated plan manager who will assist you in making the most of your NDIS plan.

To get started, please take a moment to fill in our online intake form. Please provide as much detail as possible. Fields marked with an asterisk (*) are required.

Once completed, simply click the rectangle “Submit” button to send us your information.

If you have any questions or uncertainties, please don’t hesitate to call us at 1800 975 400. Your NDIS plan, your way – let’s start the journey together

Participant Full Name *

First

Last

Date of Birth (DOB) *

Gender

Male
Female
Non-identified

Street Address *

Suburb *

State *

Post Code *

Participant Phone Number *

Participant Email *

Participants NDIS Plan *

9 digit reference number located in the top left of your NDIS Plan.

NDIS Plan Start Date *

Your NDIS start and end date can be found within your NDIS plan.

NDIS Plan End Date *

Your NDIS start and end date can be found within your NDIS plan.

Representative / Support Contact Person *

First

Last

Representative Email *

Representative Phone Number *

Relationship to Participant *

Support Coordinator or Local Area Coordinator (LAC)

Only required if details are known.

Organisation

Email Address or Phone Number

Comments

Please add any additional information you feel my help us support you better.

Agreement *

Please select upon ageement of the below.

I agree to have provided all personal information with consent from the parties involved and as per the iConnect Plan Management Privacy Policy.

Please note:

By completing and submitting this form on behalf of an NDIS participant, you agree to have received consent to share the participant’s information with us.
The information provided within this form will be shared with other staff within our organisation on and only when
staff require the information to carry out their duties.
The participant can ask to see records and receive a copy at any time.
Records are archived for a set period according to our policy and procedures.
All information obtained will be kept confidential.
This information is used to set up your Plan Management agreement with iConnect Plan Management.

A team member will be in contact with you or your Representative via the information provided. The purpose of this call is to get to know you and understand your requirements in more detail.

A copy of your NDIS plan will also be required. In preparation for this, please download your NDIS plan from your MyGov account. If you do not have a copy of your NDIS plan or are experiencing difficulty finding it online please contact us for assistance.

Should you wish to discuss any part of this online form or the details you provide, our friendly team are available on 1800 975 400.

Additional information about Plan Management can also be found by visiting our FAQs page or the NDIS.

Plan Management Intake Form

Contact Information

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