3 Minds Qld - Expression of interest Winter School holidays 2025

Participant Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Street Address *

City *

State *

Postcode *

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Email

Street Address

City

State

Postcode

NDIS Details

Plan *

Plan Managed Self Managed Agency ManagedPrivate funding

Plan Manager Name (If Applicable)

Plan Manager Agency (If Applicable)

NDIS Number *

Available/Remaing Funding for Capacity Building Supports

Plan Start Date *

Plan Review Date *

Client Goals (As stated in the NDIS plan) *

Referrer Details (Person Making the Referral)

First Name *

Last Name *

Agency

Role

Email Address *

Phone Number *

I have obtained consent from the participant to make this referral and provide the participant's personal and medical details. *

� General Information – Holiday Program

All activities are delivered by 3 Minds QLD and are billed in line with the current NDIS Price Guide.

� Location:
All programs start and finish at:
3 Minds QLD – Shop 4a, 73–77 George Street, Beenleigh

� Hours of Support:
Standard program hours are 9:00 AM to 3:00 PM, unless otherwise specified in the activity details.
Extended hours may be available on request and will be billed accordingly.

� Price Structure:

1:1 Support: $67.56 per hour
1:2 Support: $33.78 per hour
Travel: $1.00 per kilometre
- Travel for group outings is split between participants
- Additional transport (e.g. pick-up/drop-off) is charged per km, either at full rate for 1:1 or divided among those sharing transport

� Pick-Up & Drop-Off:
Available upon request at an additional cost. Please advise at time of booking.

� Out-of-Pocket Expenses:
Some activities include a set fee for participation (e.g. tickets, snacks, materials). This amount is noted in the activity details and is not claimable under NDIS funding.
Any extra items participants may choose to buy (e.g. souvenirs, café food, personal purchases) are the responsibility of the participant or guardian.
Payment of all out-of-pocket expenses is required prior to attending and can be transferred directly to 3 Minds QLD.

We aim to offer a flexible, fun, and inclusive program that balances routine, creativity, and community engagement in a safe and supportive environment.

Days for holiday program

30-07-2025 Monday Movie Magic Centre based day

Select a Service

Support required - Day 1 *

1:1 support1:2 supportNot attending

Transport - Day 1 *

Pick upDrop offNot applicable

Additional information

01/07/2025 Tuesday Ipswich Rail Museum

Select a Service

Support requried Day 2 *

1:1 support1:2 supportNot attending

Transport required - Day 2 *

Pick upDrop offNot applicable

Additional information

02/07/25 Wednesday Centre-based Sensory Play and Art

Select a Service

Support required Day 3 *

1:1 support1:2 supportNot attending

Transport Day 3 *

Pick upDrop offNot applicable

Additional information / comments

Thursday Community access Train to Southbank for a Picnic lunch & play

Select a Service

Support required Day 4 *

1:1 support1:2 supportNot attending

Transport Day 4 *

Pick upDrop offNot applicable

Comments

04/07/2025 Friday Centre based activity Cooking and music

Select a Service

Support required day 5 *

1:1 support1:2 supportNot attending

Transport Day 5 *

Pick upDrop offNot applicable

Extra information

07/07/2025 Monday Community activity Glow worms at Mt Tambourine

Select a Service

Support required day 6 *

1:1 support1:2 supportNot attending

Transport Day 6 *

Pick upDrop offNot applicable

Additional comments

08/07/2025 Tuesday Craft & Snack Making fun at the Centre

Select a Service

Support required day 7 *

1:1 support1:2 supportNot attending

Transport Day 7 *

Pick upDrop offNot applicable

Additional comment

09/07/2025 Wednesday Cross River rail experience & Pancake Manor

Select a Service

Support required day 8 *

1:1 support1:2 supportNot attending

Transport 8 *

Pick upDrop offNot applicable

Extra

10/07/2025 Thursday Centre based 1:1 Board Games and build day

Select a Service

Support required day 9 *

1:1 support1:2 supportNot attending

Transport day 9 *

Pick upDrop offNot applicable

Extra Information / Comment

11/07/2025 Friday 1:1 Local explore and dance party

Select a Service

Support required day 10 *

1:1 support1:2 supportNot attending

Transport day 10 *

Pick upDrop offNot applicable

Comment

Medical information & Disability Details

Diagnosis/Primary Disability: *

Secondary Diagnoses (if any): *

List of supports comments

Mobility – Select all that apply or describe as needed *

Walks independently – no support requiredWalks with minimal supervisionRequires verbal prompting for safe walkingNeeds physical assistance on stairsRequires support getting in and out of vehiclesUses a walking frame or rollatorUses a walking stick or crutchesNeeds support with uneven terrain or long distancesOther (please specify): ___________________________

Other Mobility / Comments (please specify): ___________________________

Medication (Taken During Service Hours)

Medication *

YesNoNA

Personal care & Toileting support checklist

Eating & Drinking Support *

Eats independentlyNeeds supervision while eatingRequires physical support while eatingRequires food cut into small piecesRisk of choking – staff to observe closelyDrinks independentlyRequires support with drinks (e.g. straw, cup assistance)Known allergies or dietary restrictions (please list): ___________________Uses adaptive utensils (please specify): ___________________

More information - Eating and drinking support

Upload eating and drinking plan if required

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Food preferences additional information

Travel & Seating Supports additional information

Communication Needs *

VerbalNon-verbalUses visual aids / key word signs / gesturesNeeds support understanding instructionsNeeds extra time to respondBest communication approach: ___________________Uses AAC device (please describe): ___________________

Communication needs additional information

Behavioural Supports / Alerts additional information

Upload behaviour plan if required

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