Mildura Disability Support Intake Form

Mildura Disability Support Intake Form
Participant Name*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Participant Phone Number*
Client's Phone Number*

Phone Number
Participant E-mail*
example@example.com
NDIS Number*
Participant Gender:*

FemaleMale
Participant Address*

Street Address

CityState

Postcode
Country of Birth:
Participant occupation if applicable?
Are there any cultural considerations we need to be made aware of?
Preferred contact person?*
Participant primary disability?*
Other medical conditions (if any)?
If the Participant suffers from asthma, epilepsy, diabetes, or anaphylaxis, please upload a copy of the emergency management plan

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For payment of MDS invoices, is the client's plan self or plan managed?*

Plan ManagedSelf Managed
What is the name of the Plan Manager & email address?*
NDIS Plan Dates? *
Please upload a copy of the current NDIS plan or stated goals.

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What is the dollar amount allocated within in the NDIS plan for core supports?
Is the Participant taking any medication? If so, please state dosage and frequency. *
Are MDS required to give the Participant medication during their support time? If yes, please complete a medication authority form below. Medication will also have to be signed in by support workers when handed to them.*

YesNo
If medication is required to be administered by Mildura Disability Support, please complete a medication authority form here: https://form.jotform.com/243256824968066

Please note, we are unable to give medication if the form has not been completed.
What does the Participant like to do? List interests/hobbies/things they do for fun? *
Support Coordinator's Name
Support Coordinator Company, Phone number & email address
What NDIS funded service/s days & times are you requesting through Mildura Disability Support? Please included days, times and types of supports. *

What NDIS funded service/s days & times are you requesting through Mildura Disability Support? Please included days, times and types of supports. *

	Times Eg: 3.15pm to 6.15pm	Instructions or Activities? Eg: Pick up from day school & take to gymnastics
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

What is the service start date?*
Reason for Referral?*
Current services being received by the Participant eg OT, Physio, Psychologist behaviour, speech etc. If so please upload any relevant reports (eg Functional Capacity report) that will help us better manage the Participant.

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Please list any risks issues we need to know that might pose a risk to the staff or the Participant. (For example: aggressive/violent behaviour, absconding, IVO's, Court Orders, drug/alcohol issues, animals at the property)*
How did you hear about MDS?

Word of MouthFacebookGoogleSupport CoordinatorLinkedInOther
Person Completing the Form*
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty: