New Client - NDIS Participant Details (person who the nutrition advice is for):
Full Name (required)
Date of Birth (required)
Mobile Phone No. (required)
Home Phone No.
Participant's Email (required)
Please complete if you are filling out this form on behalf of an NDIS participant:
Mobile Phone No.
Relationship with Participant
Address (if different from above)
NDIS Plan Details
NDIS Participant No. (required)
Plan Dates (required)
Who manages the NDIS funding? (required)
NDIS ParticipantOther: Nominee/Plan Manager
If other, please provide details for invoicing:
Nominee/Plan Manager/Organisation name (required):
Nominee/Plan manager/Organisation address (required):
Email invoices to (required):
Who coordinates appointment bookings (if different from above)? (required)
If other, please provide details for the person managing bookings (this person will receive appointment confirmation emails and SMS appointment reminders):
Please provide some information about why this participant is booking with a dietitian: (required)
How did you hear about The Healthy Eating Clinic? Select ONE only (required)
HerCanberraFacebookInstagramGoogleThe Hub MembershipShopfrontWord of MouthThe Daily Dollop PodcastHealth Professional (please specify)Client (please specify)Gym (please specify)Other (please specify)
When you book an NDIS appointment with The Healthy Eating Clinic you will be required to agree to and sign a separate service agreement outlining the conditions of NDIS services provided by The Healthy Eating Clinic.
Thank you for your time. A member of The Healthy Eating Clinic team will be in touch with you within 48 hours to discuss your referral.