Intake Form

Intake Form
Is this intake form for support coordination or disability support services?*

Disability SupportSupport Coordination
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
Communication Type*

VerbalNon-VerbalCommunication aid requiredOther
Other:
Country of Birth:
Is the participant Aboriginal or Torres Strait Islander descent?

YesNo
Preferred method of communication is:

PhoneSMSEmailMail
Participant Living Situation

Living IndependentlyLiving with familyLiving in supported accomodationTemporary (relatives, friends, other)At RiskHomelessOther
Other:
Physical Health

AsthmaEpilepsyVisual ImpairmentCognitive ImpairmentSleep AponeaDiabetesHeart conditionsHearing ImpairmentBlood DisordersOther
If other selected above, please provide details
Do you have a current Behavioural Support Plan?*

YesNo
Upload Current Behavioural Support Plan if applicable

Cancelof
Participant occupation if applicable?
Are there any cultural considerations we need to be made aware of?
Are there any legal issues that may affect our service? If applicable, please provide details
Any other relevant information?
Preferred contact person?*
Advocacy form supplied?*

NoYes
Emergency contact - name: (if an emergency contact has already been listed above, please list a second here)*
Emergency contact relation to participant:*
Emergency Contact- phone number*
Emergency contact - email
example@example.com
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 ManagedNDIA Managed
What is the name of the Plan Manager & email address?
NDIS Plan Dates? *
Please upload a copy of the current NDIS plan or screenshot of participant NDIS Goals.

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Which funding is the supports being billed from? Eg Core or Capacity Building. If unknown, leave blank.
What Mildura Disability Support services do you require? In-home & community supports

Assistance in Coordinating or Managing Life Stages, Transitions and SupportsDaily Personal activitiesAssistance with Travel/Transport ArrangementsInnovative Community ParticipationDevelopment of Daily Living and Life SkillsHousehold TasksParticipation in Community, Social and Civic Activities
Supported independent living/Respite Care/Group

Assistance with Daily Life Tasks in a Group or Shared Living ArrangementGroup and Centre Based Activities
Professional Registration Groups

Specialist Behaviour SupportImplementing Behaviour Support Plans
Mildura Disability Support Services can assist me by ….
Is the Participant taking any medication? If so, please state dosage and frequency. If none, type NA*
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
I would like assistance with managing my medication by:
Mental Health

DepressionAnxietyPost Traumatic Stress DisorderPsychosisObsessive Compulsive disorderAnxietyBipolarSchizophreniaMood DisorderOther
If selected OTHER above, please provide details
Medications for mental health? Please list
History of hospital admission?

YesNo
If yes above, please provide further details
I would like assistance with managing this by:
Dietary Requirements

YesNoVegetarianDairy FreeGluten FreeVegan
Allergies, please list
I do not like to eat: (please list)
My favourite food is:
Practical Support needs: I require assistance with:
Mobility

IndependentAssistWalking StickWalking FrameManual hoistShower chairOther
Personal Care

Shower/BathGroomingToiletingDressingBrushing teethShavingOther
If selected other above, please specify
YOUR PREFERENCES
Do you have specific preferences when matching staff?*

FemalesMalesNo preference
Worker Age Group Preference *
Culture/Religion/Ethnicity
Languages spoken
Personality characteristics
Specific needs, skills or knowledge required?
Specific training that may be required to provide services and support to you?
Is there anything else you would like us to know about you that is important for how we provide our services to you?
What are your goals, expectations and desired outcomes when receiving our services?
What are your goals for the next 12 months?
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 (if applicable)
Support Coordinator Company, Phone number & email address (if applicable)
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
Not required (type NA - if intake is for support coordination)

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
CONSENT AND ACKNOWLEDGEMENT

By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.
Do you consent to participating in and use of:*

Participating in audits of our business by the NDIS Commission and its auditorsPhotos for Social MediaPhotos for our websiteNone of the above
Person Completing the Form*
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty: