Mildura Disability Support Intake Form
Client Name
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First Name
Last Name
Date of Birth:
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Day
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Month
Year
Date
Client's Phone Number
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Please enter a valid phone number.
Client's E-mail
example@example.com
NDIS Number
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Client's Gender:
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Female
Male
Client's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country of Birth:
Client's occupation if applicable?
Are there any cultural considerations we need to be made aware of?
Preferred contact person?
Client's primary disability?
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Other medical conditions (if any)?
For payment of MDS invoices, is the client's plan self or plan managed?
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Plan Managed
Self Managed
Is the client taking any medication? If so, please state dosage and frequency.
What does the client like to do? List interests/hobbies/things they do for fun?
What is the name of the Plan Manager & email address?
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NDIS Plan Dates?
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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?
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.
Reason for Referral?
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Current services being received by the client eg OT, Physio, Psychologist behaviour, speech etc
Please list any risks issues we need to know that might pose a risk to the staff or the client. (For example: aggressive behaviour, absconding, IVO's, Court Orders, drug/alcohol issues, animals at the property)
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Person Completing the Form
Signature
Date
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Day
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Month
Year
Date
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