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How to apply for NT Companion Card

Note: this application is for NT Companion Card only. For other states and territories, see the Department of Social Services website by clicking here.

Step 1

Apply by filling the online application form at the bottom of this page.

Alternatively, you can fill in and print a PDF version by clicking this Companion Card application form link.

 

You can either:

  • contact your disability coordinator, allied health professional or aged card coordinator who can help you fill in the form
  • or fill in the Companion Card application form with the help of a health professional such as your doctor.

Step 2

Get two colour, passport-sized photographs of yourself.

These must be signed on the back by the same person who completes section four of the Companion Card application.

Example passport-sized photographs:

Step 3

Submit your application form by clicking the “Submit” button after completing the form below. If filling the PDF version, complete the PDF form then send it and the photographs by mail to:

NT Companion Card Program
Integrated disAbility Action
PO Box 645, Nightcliff NT 0814

You may be asked to submit medical information about your disability to support your Companion Card application.

Declined applications

Your Companion Card application might be declined if any of the following apply:

  • you have a temporary impairment
  • you do not need lifelong attendant care support to access the community
  • the lifelong need for care and support in the community can’t be determined
  • you can’t access a particular venue
  • you choose to have a companion for social company or reassurance
  • you experience infrequent or unexpected events such as allergic reactions, falls or medical emergencies
  • you can use available aids, equipment or alternative strategies to access a venue or activity.

If your application for a Companion Card is declined, you can request a review by calling IdA on 08 8948 5400 or email info@ntcompanioncard.org.au.

You may need to submit more information to support your application.

 

NT Companion Card Application Form

SECTION ONE

Note: for NT residents only. See Department of Social Services website if applying for another state or territory.
The Applicant is the person with disability. Please complete the form in relation to the applicant.
E.g., Mr/ Mrs/ Miss/ Mx...
Name(Required)
Gender
Date of birth(Required)
Residential Address(Required)
Postal Address (if different from above)
Are you an NDIS participant?(Required)
We offer a digital version of the NT Companion card. It can be used with Google Pay and Apple Pay. You will also receive your physical copy. Would you like a digital card, too?

SECTION TWO

If your need for attendant care to access the community is not permanent, you are not eligible to receive a NT Companion Card. Please tick the boxes and describe your disability. We have provided some examples of diagnoses or conditions to assist you to complete this section. (You can tick more than one box)
Physical (eg: muscular dystrophy, quadriplegia, cerebral palsy)
Max. file size: 256 MB.

Neurological (eg: Alzheimer’s disease, Huntington’s disease)
Max. file size: 256 MB.

Sensory (eg: deaf, blind, legally blind)
Max. file size: 256 MB.

Acquired Brain Injury (eg: stroke, head injury)
Max. file size: 256 MB.

Intellectual (eg: Fragile X syndrome, Rhetts syndrome)
Max. file size: 256 MB.

Mental Health (eg: schizophrenia)
Max. file size: 256 MB.

Max. file size: 256 MB.
Please remember to attach supporting documents to demonstrate disability and describe attendant-care need. These may be formal assessments or reports relating to your disability or a supporting letter from your health professional/service provider.

SECTION THREE

Please describe your need for life-long attendant care support in the areas of mobility, communication, self-care and learning when accessing a community event or venue. Assistance required Minimal – can perform 75% or more of the task Some – can perform 50% to 74% of the task Substantial – can perform less than 50% of the task
Mobility
Communication
Self-care
Learning, planning and decision making
Other

SECTION FOUR

Registered Health Professional/Service Provider to complete.
Please indicate your position:

Health Professional/Service Provider Declaration

I acknowledge that the information provided in Sections Two and Three of this application, is in my professional opinion, a true and accurate reflection of the applicant’s disability and attendant care needs based on the information that has been presented to me and I confirm that I have written the applicant’s name and signed the reverse of both photographs to verify that they are of the applicant.
Health Professional/Service Provider's name(Required)
Address

Cardholder or decision maker declaration and authorisation

I confirm that my signature below verifies that:
✓ I am a resident living in the NT;
✓ I have a permanent disability and I will always require (or am always likely to require) attendant care support to participate at most activities and events in the community;
✓ I consent to Integrated disAbility Action contacting me (or my authorised contactpersons) and my supporting health professionals/disability service provider to verify the information provided on my renewal application, or to obtain further information regarding my eligibility;
✓ I agree that health professionals or service providers may disclose information about me to the Companion Card program to assist with the assessment of my application;
✓ I will advise the NT Companion Card Program of any changes in my circumstances that may affect my eligibility to hold a card;
✓ I certify that the information in this application is correct;
✓ I understand and accept the Cardholder Terms and Conditions; and
✓ I understand it is an offence to provide any false information in this application.
Dated
OR - Where the individual is a child, the parent/ guardian's signature:
Dated
OR - Where the individual lacks capacity, the legal guardian’s signature:
Dated
Max. file size: 256 MB.

Lastly, please upload two passport-sized photographs

Upload two colour, passport passport-sized photographs of yourself. The photographs must be a full front view of your head and shoulders only. Photographs must be no more than six months old.
Write your name on the back of both photographs and have them signed by the professional who signed section four. Upload both the front and back of the photographs.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.
This field is for validation purposes and should be left unchanged.