• 1800 953 997
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Contact Info

  • 1800 953 997
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Date of Birth *
Address *
Language Spoken *
Does the Participant live alone? *
Interpreter Required *
Is the participant supported by only one support worker? *
NDIS Plan Manager *
What Support Services are you looking for? (Select all applicable). *
Service Start Date *
Service End Date *
Support services Start Date
Is the participant at risk of choking, seizures or anaphylaxis? *
Is assist with medication administration required? *
Does participant suffer from irritants, phobias or any other specific condition? *
Is participant home easy to locate? *
Are any gates or doorways difficult to use or access? *
At night, is the house entrance hard to find? *
Do you give consent for the support worker to proactively support you in attending medical, and allied health services? *
Any pets or animals at home? *
Is onsite/street parking available for support worker’s car? *
Is there a risk that participant may abscond? *
Do you give consent to share this form with your support network, other providers, and relevant government agencies? *
Is the home wheelchair accessible? *
Are there any slip, trip or falling hazards outside or inside the home? *
Will the support worker be required to use any electric appliances? *
Click or drag a file to this area to upload.
How did you hear about Us? (Select all applicable). *
Date *

About Us

As a Registered NDIS provider, Cosmos Divine Care provides services in a unique manner. Every participant receives a personalized approach and our services are tailored to meet the needs of each individual.

The Cosmos Divine Care team acknowledges the traditional owners and custodians of the country throughout Australia. We acknowledge their continuing connection to land, sea, and community. Respect is expressed to the people, the cultures, and the elders past, present, and emerging.

Contact Info

Office (by Appointments Only)

  • 40 Le Page Run, South Morang, 3752 Victoria
  • 1800 953 997
  • info@cosmosdivinecare.com.au

Further Information
What is NDIS?
Support Network - Ask Izzy
About COVID-19
NIDS Pricing

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