New Customer Registration Form

New Client Form:

4ability are committed to providing services to you in a way that respects your cultural, diverse values and beliefs and communicate with you in a mode, language, terms and in communication you understand.
PERSONAL DETAILS

Participant and Representatives
Full Name*

First NameFamily namePreferred Name
Date of Birthday*

DayMonthYear
Gender*
Referred By:*

NDISFriend/FamilySelf ReferredOther
Participant Contact*

Street Address

Street Address Line 2

CityState

Postal CodeCountry
Participant E-mail
example@example.com
Participant Phone Number

Area CodePhone Number
Participant has a Guardian or Representative that helps to make decisions

YesNo
Guardian or Representative information

First NameLast Name
Guardian or Representative Contact

Street Address

Street Address Line 2

CityState

Postal CodeCountry
Guardian or Representative E-mail
Guardian or Representative Relationship
Ex. Mother, Father, Sister
Guardian or Representative Phone Number

Area CodePhone Number
What Disability Or Medical Diagnosis is Present?*
Describe about client disability
NDIS FUNDING DETAILS

Client NDIS details
NDIS Number*
ex:01234
Funding NDIS Type:*

Plan ManagedNDIS agency ManagedSelf Managed
Plan Managed Details
name/phone/email
NDIS Plan Period
Start and End of Plan Date
Intensity of Support*

StandardComplexIntense
Copy of NDIS plan?

YesNo
SUPPORT TO BE PROVIDED

How you need to be supported
Types of Support

Daily Personal ActivitiesHelp around the HouseIn home SupportPersonal CareCommunity and Social assistanceEducation, training or employmentTransportSpecialist SupportOther
Details of Support Requirements
For example, bowel care needs, medication assistance, PEG feeds
Preference Gender of Support

malefemaleno preference
Support to be provided

Individual 1.1Group 1.2Group 1.3Group 1.4
Days/ Times Supports To Be Provided
For example Wednesdays 09:00-12:00
Are support:

Flexible in times and DaysTo be provided on public holidays
CLIENT PROFILE

More about the client and the support to be provided
Any Know allergies?
List all Know Allergies
What languages do you Speak?
List the languages
Cultural Diversity ?

AboriginalTorre Strait IslanderAboriginal and Torre Strait IslanderNoPrefer not to Say
About Me*
Medical History*
Support Plan

This information will be shared with Support workers. When scheduling intake meeting ensure that you have asked the client if they want any family members, advocates, legal guardian, close persons or friends to attend the meeting and ensure meeting is scheduled to promote inclusion of these people. Inform the participant that it is their right to have someone attend the intake meeting with them, and should they wish to invoke this right that 4ability will work around the client and their family to support their decision making, rights and wishes. Before commencing support plan ask the client if there is anyone that they would like present during the creation of the support plan, or offer to phone the person into the meeting to make recommendations if client wishes.
GOALS, MOBILITY, COMMUNICATION, BEHAVIOR, PERSONAL CARE AND MEDICATION
What is important to me*
Do you have any cultural, diversity, specific values or beliefs that you would like to inform us about or to centre your supports around?*
What Are My Goals? *Services Must Be Consistent With NDIS Plan Goals.*
Client Required Support or Assistance with Mobility?
Describe with type of support and assistance need
Client Required Support or Assistance with Communication?
Describe
Are there any Behaviour of Concern present? Describe Types
Is a behaviour management plan in place?

YesNo
Is any Personal Care needed during Shift?*
Describe
Is any Mealtime Assistance needed?*
Describe
Is the participant taking any prescribed medication?*
If yes describe with medications.
Will be support worker be required to be assisted with medication?

YesNo
SAFETY ASSESSEMENT - COMMUNITY
Transport for support*

Public TransportSupport Worker CarOther
Are there any Risk associated with transport*

YesNo
If yes, Describe the Risk
Are there any places, situations or specific irritants that Should be avoided?*
Describe place, situations, exemplos.
Is there any risk or past history of Absconding?
Describe and give ex.
Any consideration or Risk to Support the Client in the Community?*
Describe and give ex.
SAFETY ASSESSEMENT - CLIENT HOME
Safety Checklist at Client Home

Electrical Appliances and Power cord are in good conditionSmoke alarmThe fuse box is fitted with a safety boxEmergency ExitsPower points near waterStove and OvenHazard Substances
Type of Residence
home/unit/group home

Support Work working at clients Home

	Yes/No
Is the home difficult to locate?
Is parking available for support worker?
Are any gates or doorways difficult to use or access?
Are there any slip, trip or falling hazards?
Is the home Wheelchair accessible?
Any Pets around or in home?
Will the support worker required to use any electrical appliance?
In case of emergency at home, do you know the procedure?

Is there Anything else you would like to share about the home?
Describe and give ex.
I have had sufficient time to think about my options and seek advice should I need it during the creation of my support plan. I agree to my support plan and have created my support plan with my chosen people to help me , which has been supported by 4ability. I acknowledge that it has been explained to me that my support plan will last during my current service agreement, but if I need to change it I can contact 4ability on 0425331302 or contact@4ability.com.au and ask to have it changed, and understand that this will be actioned within 5 business days. I have informed 4ability of any recommendations from my therapists or health professionals. I acknowledge that 4ability has asked me if I have any cultural, diversity, values or beliefs that I want 4ability and workers to know about or to centre my support around. I acknowledge I have informed 4ability about how I want my supports to be delivered and that I have the right to practice dignity of risk and that I will be supported sensitively to do this, by 4ability. Lastly, I acknowledge that my legal and human rights have been explained to me in a way that I understand them.
Name

First NameLast Name
Signature *

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Date*

DayMonthYear
Date
CONSENT TO SHARE INFORMATION

4ability PTY Ltd
4ability will comply with relevant privacy legislation and in the standards set for dealing with personal information outlined in our Policy, Practice Guidelines and Procedures. We aim to sensitively respond to your needs in all aspects of service delivery. Staff are trained in cultural competence and will respect your needs sensitively. Please discuss the following statement with clients before proceeding: This organisation will work closely with other agencies to coordinate the best support for you and your family. Your informed consent for the sharing of information will be sought and respected in all situations unless:·we are obliged by law to disclose your information regardless of consent or otherwise:·it is unsafe or impossible to gain consent or consent has been refused, and,·Consent to Share Information Form without information being shared, it is anticipated a child,young person or adult will be at risk of serious harm, abuse or neglect, or pose a risk to their own or public health or safety.
Primary Purpose Consent: The primary purpose(s) of this service has been explained to me and I consent to the sharing of my personal information to assist in achieving the primary purpose(s).

YesNo
I have been given time appropriate for me to consider and review my options and seek advice if required

YesNo
Proposed Use and Disclosure of my personal information: I understand that the following service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services, in order that I receive the best possible service. Information will only be discussed or disclosed that directly relates to supports or service provision.
Service type and name of agency
To ensure the client is able to make an informed decision about consent to the disclosure of their information, the service provider should complete these steps: (tick when completed)

Discuss with the client the proposed referral toother services/agencies.Explain that the client’s information will only be released if the client has agreed and advise that services will still be provided even if the client does not want information disclosed.Explain that information will be shared without consent if there is a serious threat to the health or safety of person(s), to report illegal activity or is required under law.Provide the client with our easy English guide about privacy
Record of Client Consent

My worker has discussed with me how and why certain information about me may need to be provided to other service providers.

I understand the recommendations and I give my permission for the information to be shared as detailed above.
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

New Client Form:

PERSONAL DETAILS

NDIS FUNDING DETAILS

SUPPORT TO BE PROVIDED

CLIENT PROFILE

Support Plan

CONSENT TO SHARE INFORMATION