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61 02 8877 0999 FREECALL 1800 777 175

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Program Intake Application Form

You can find out about our programs here What We Do and come back to this page when you are ready to proceed. Or, if you have any questions about the services we offer, then please do not hesitate to contact us on the MND Info Line 1800 777 175.

This Get Support form is for:

  • A person with a confirmed diagnosis of MND or Kennedy’s disease
  • A person with a NDIS plan who has a diagnosis other than MND or Kennedy’s disease
  • A family carer who is supporting a family member or friend who has MND.

It should take about 5 minutes to complete.

How we use the information you provide

The information collected below will be used to ensure we link you to the right support people and programs within our organisation.

All information provided will be held by MND NSW and used by us to provide support, information and to assist us communicate with you. We take your privacy extremely seriously and will work within all legislation and our own policies and procedures to keep your information safe. We will only share information with those people you have authorised. You can, at any time withdraw or change any of the information provided, including making changes or updates to authorised persons, by contacting us ph. 1800 777 175 or 02 8877 0999. You can view our privacy policy here or ask for a copy to be posted to you.

You will always be the first point of contact for decision making. Those authorised to speak on your behalf will only be contacted if you have asked us to do so or if you are unable to speak/communicate on your own behalf for any reason.

What happens after you submit your Form?

You will receive a confirmation of the Form submission to the email address you provide on the Form. When we receive the Get Support Form we will contact you within 2 working days. We will provide you with an MND NSW Service Agreement which will outline the services available for you, all costs (if any), details of how to terminate services as well as information about your rights and responsibilities in accessing our services. This information is provided to you so you can decide if you wish to proceed.

We will also provide you with information about our feedback and complaints processes along with links to our online resources and support group information. 

Start

Please select one option

If you are completing this form on behalf of someone else, you will be required to provide your contact details at the end of the form.

Questions marked * will require an answer. 

I am a person with a confirmed diagnosis of MND or Kennedy’s disease

I am a person with a NDIS plan who has a diagnosis other than MND or Kennedy’s disease

I am a family carer who is supporting a family member or friend who has MND

Please select one option
Please type your First Name
Please type your Last Name
Please enter your Date of Birth
Home Address
Please type your Street
Please type your Suburb/Town
Please type your Postcode
Please type numbers
Please type numbers
Invalid email address.
Mailing Address (if different to the above)
Invalid Input
Please type your Mailing Suburb/Town
Please type your Mailing Postcode
Details
Please select one option
Please select an option
Please select
Please select an option
Please select
Please select an option
Please select an option
Please select an option
Please select an option
Your health, disability or medical condition

If you are not sure of the dates, please make a best estimate. We can always update these dates from information you provide to us in the future.

Please type your primary diagnosis (eg MND)
Please make an estimate of your date of diagnosis
Please make an estimate of your date of symptom onset
Alternate Contact

By providing us with an alternate contact, you and the alternate contact consent for MND NSW to create a record and consent for MND NSW to communicate with them about your care needs, if required. Please note that an MND NSW staff member will seek direct confirmation from the person seeking Program entry unless it is not practical to do so.

Please choose a response
About the Person MND NSW may communciate with
Please select one option
Please type your Alternate Contact's First Name
Please type your Alternate Contact's Last Name
Please type only Letters
Invalid email address.
Please type numbers
Please enter letters and numbers only
Please type only Letters
Please only type numbers
Please make a selection
Consent to record (required)

In completing this form, you are giving your consent for MND NSW to record your personal information and create a health record. MND NSW will provide a separate service agreement for each program you are eligible for. You can choose to accept or decline service agreement/s provided to you by MND NSW. 

Please provide your consent for MND NSW to record your personal information and create a health record.
Please select Consent Date
Completing this form on behalf of someone else?

If you are completing this form on behalf of someone else, please provide your details:

Please type Letters only
Please type Letters only
Please type only Letters
Invalid email address.
Please type numbers
Invalid Input