Section 2: Completed by the Treating Professional

Part A: Treating Professional’s Information

The National Disability Insurance Agency (NDIA) collects your personal information, such as name, contact details, and qualifications to process the applicant’s NDIS application. We may need to communicate with you about the applicant’s request while we are determining their eligibility for the NDIS.

Applicant’s Treating Professional
1. First name:
2. Surname:
3. Professional qualification(s):
4. Provider registration number:
5. Length of time you’ve treated the applicant:
6. Business address:
7. Phone:
8. Email: