How did you hear about ProActiv People?Autism SACentrelink / Services AustraliaFacebook/InstagramGoogle SearchSupport Coordinator or ProviderWord of Mouth

Does the client have a confirmed diagnosis of Autism/Aspergers Syndrome *

YesNo

Thanks for your interest in ProActiv People. Our current services under the
Inclusive Employment Australia (IEA) Program is specifically for individuals,
with a diagnosis of Autism or Aspergers Syndrome.

If you're looking for employment support and don't have a diagnosis of Autism or Aspergers Syndrome,
you may be eligible for other programs through Centrelink / Services Australia.

You can either visit Services Australia
or call the National Customer Service Centre on 1800 805 260

Participant Information

First Name *

Last Name *

Preferred pronouns

Preferred name

Date of Birth *

Customer Reference Number (CRN):

Address

Suburb *

Email Address *

Phone number *

Does the participant have a current NDIS plan? *

YesNo

If yes - please provide current NDIS Plan Dates

Preferred contact

Is this the same as the participant? *

YesNo

Contact name *

Phone *

Email *

Contact person relationship

Reason for Referral / Requirements Requested

Please enter specific needs: *

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