Welcome to Gurri Wanyarra Wellbeing Centre

The Gurri Wanyarra Wellbeing Centre is Bendigo's premier aquatic & wellness centre, with an Olympic-sized 50m indoor pool, swim school, large health club, group fitness, spa & sauna, wellness pool, and Bendigo's only indoor splash park!

NDIS Referral Form - Exercise Physiology

CLIENT DETAILS

MrMrsMissMsMxDrOther

First Name *

Last Name *

Preferred Name/Nickname *

Date of Birth *

Sex: *

MaleFemale

Gender *

MaleFemaleNon-binaryTransgender MaleTransgender FemaleOther

ATSI *

AboriginalTorres Strait IslanderNone of the Above

Ethnicity/Cultural Background *Please describe your ethnicity and/or cultural background so we can better cater to your needs and treatment plan

English is your Second Language *

YesNo

CLIENT CONTACT DETAILS

Contact Phone no.

Address: *

Street address *Street address line 2

City *

State *

Postcode *

Country

NDIS No. *Your NDIS no. has 9 digits

Plan Start Date: *

Plan End Date: *

Support Coordination Company

Support Coordinator Name:

Support Coordinator Email:

Funding Category for Exercise Physiology *

Health & WellbeingDaily Living Skills

This is essential to provide to ensure a smooth process and for us to bill correctly

Management of Funds *

Plan ManagedSelf-Managed

Unfortunately, we are unable to accept NDIA/Agency Managed participants for this service

Plan Manager Company

Plan Manager Email

Budget/Funding Availability:Please provide funding availability $/hrs

NDIS related Conditions/Disabilities *Please provide funding availability $/hrs

NDIS Goals *

Availability for appointments

Please attach a copy of NDIS Plan

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Who is completing this referral? *Referrer

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