Intake Form

1. Participant Details

Particpant Name *

D.O.B *

Gender *

Landline:

Mobile:

Email:

Language spoken at home:

Interpreter required: *

YesNo

Preferred option for communication:

PhoneEmailPost

Residential Address:

Street address

City

State

Postcode

Do you indentify as Aboriginal and Torress Strait Islander?

YesNo

Is there a Guardianship and/or Administration order in place? *

YesNo

For participants under guardianship or in the care of family or caregivers please complete below:

Relationship to Participant:

ParentGuardianCaregiverOther

Other:

Name

Landline

Mobile

Email

2. Disability/Medical Conditions including any diagnosis if relevant

Enter details: *

3. Type of Support required

(In home, community participation or Support Coordination/Recovery coach) including day and time of support. Eg: Community Participation- Mon, Wed and Fri – 9am-3 pm)

Enter Details: *

4. Other service providers currently engaged:

Name:

Contact Details (Phone/Email):

Frequency of use:

5. Health Care Information
(General Practitioner, Specialist, Pharmacy etc)

Name

Phone No

Address

6. Funding

NDIS Number:

NDIS Plan (Start/End date)

How is the funding managed? *

NDIS ManagedPlan ManagedSelf Managed

Please provide details for invoices:

Name

Email

Comments

7. Preferences

1. Preferred Name

2. Religious requirements

3. Cultural Requirements

4. Other Considerations

8. Goals & Aspirations

What do you want to achieve for yourself – life skills, physically, socially etc?

Enter here

I understand that:

These records are owned by this organisation.
Information within these records will be shared with other staff within the organisation only when staff require the information to carry out their duties
I can ask to see the records and receive a copy
Records are archived for a set period according to policy and procedure
I understand that all information obtained will be kept confidential.

To the best of my knowledge, the information provided in this form is true and correct:

Name of the referrer

Date

Relationship to the participant