Print Envelope Share-alt Schedule your visit Book an appointment 0434 813 355 Filll in the form 1. Participant Details First name Date of birth Gender Please select Male Female Preferred Name Cultural Background Address Postal Address (if different from above) Mobile Phone Email Language Spoken at Home Interpreter Required Yes No Preferred Option for Communication Email Post Phone Do you identify as Aboriginal and Torres Strait Islander? Yes No NDIS Funding type: NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIS managed participants) Self-Managed Plan Managed NDIS Number: NDIS Start Date NDIS End Date 2. Representative Details Name of Representative Lives with Participant Yes No Relationship to participant Parent Guardian Caregiver Other Address Phone Email Preferred method of contact 3. Emergency Contact Details Is emergency contact the same as above? Yes No Name of emergency contact Lives with Participant Yes No Relationship to participant Parent Guardian Caregiver Other Address Phone Email Preferred method of contact 4. Health Care Information Medicare Number Expiry Date Reference Number Private Healthcare Provider Membership Number Reference Number 5. About the Participant Living situation Living alone in my own home Living with my family Supported Accommodation Temporary Other Types of Disability Religious / Cultural Requirements Does the participant need physical assistance equipment or support? Does the participant need assistive devices for communication Is the participant visually impaired Does the participant have any dietary requirements Does the participant have any swallowing difficulties Other considerations Does the participant have a current behavioural support plan? Yes No IF yes, please provide the details of your behaviour practitioner Practitioner’s Name Contact Number Address Medical condition/diagnosis Allergies Please provide details of your medical practitioner Name Contact Number Address 6. Name of other current service providers Name Address Phone number / Email Emergency contact Frequency of use Type of service 7. Goals What do you want to achieve for yourself – life skills, physical, social etc? Short-term goals Long term goals 8. Consent Please sign below to show that you agree with the information in this client intake form. The intake form was completed by Participant Signature Parent/caregiver signature Name of the person signing Relationship to the participant, if not the participant Date I accept the Terms of Service Submit
