Referral Form - Alligator Cleaning

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Melbourne, Brisbane & Perth – 1300 570 100

Alligator Cleaning

Home Cleaning Services

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Ndis Services

- Step 1 of 2

Participant Details

Date of referral *

Participant consented to referral? *

Yes
No

Paricipant Name *

First

Last

Date Of Birth *

Gender *

Male
Female
Other

NDIS NUMBER *

PLEASE PUT 9 DIGITS NDIS NUMBER

NDIS Plan Start Date *

NDIS Plan End Date *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone *

Email

Disability-

Emergency Contact Details

Emergency Contact Name *

First

Last

Emergency Phone *

Relationship *

Support Coordinator and Plan manager Details

Name *

First

Last

Organisation *

Position *

Phone *

Support Coordinator's Email *

If no support coordinator then please type " [email protected]"

Plan Management (Payment) *

Your Email Address *

Plan Manager's Email Address *

Preferred Service Day & Time *

Please tick following Service/s *

General Cleaning $56.23 per hour for each Cleaner (minimum 3 hours required)
General Gardening $55.21 per hour for each Gardener (minimum 2 hours required)
Handyman $250 (Initial Visit)
Support Worker $67.56 (minimum 3 hours required)
Pest Control (Quote required)
Rubbish Removal (Quote required)

I Accept terms and condition

Frequency for Cleaning Services *

Per Session (Cleaning) *

Frequency for Gardening Services *

Per Session (Gardening) *

Frequency for Handyman Services *

Per Session (Handyman) *

Per Session (Handman) *

Frequency for Support Worker *

We also provide

Spring Cleaning (declutter)
Window Cleaning
Gutter Cleaning
Pest Control
Carpet Cleaning
Rubbish Removal

Please Tick if any of the services required.

Special Instructions *

Name

Get In Touch

10 Doris Ct, Springvale South VIC 3172, Australia

Melbourne – 1300 570 100

27 Woodloes St, Cannington WA 6107, Australia

Perth – 1300 570 100

2 Wistaria St, Sunnybank Hills QLD 4109

Brisbane – 1300 570 100

[email protected]