New Client Joining Form

New Client Joining Form
We will make sure to help every single client individually to reach their own goals. Therefore we have a joining form that needs to be completed so we can help manage the clients needs.

All information provided will be treated in confidence and held under the data protection act. A member of the Live A Little staff may need to contact you to discuss the application futher.

Thank you.
Participant Full Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Contact Information
Primary Emergency Contact

First NameLast Name
Phone Number (Primary)
Relationship to Participant
Secondary Emergency Contact

First NameLast Name
Phone Number (Secondary)
Relationship to Participant
Care & Health Information
YesNo
YesNo
If yes, please provide more information below
Please answer the questions below carefully
Please note of any allergies / allergens to be avoided
Any special dietary requirements?
Does the participant require any medication? If yes, please provide as much information as possible. (Name of medication, Dosage & frequency)
YesNoNot Applicable
YesNo
Yes, I authorise Live A Little to administer emergency medication.No, I do NOT authorise Live A Little to administer emergency medication.
YesNo
If yes, how frequently does the Participant have seizures? And when was the last time they had one?
Any behavioural triggers or potential risks, safety issues that Live A Little staff should be aware about?
Risk Assessment
Risk Assessment Plan: For assessing and managing foreseeable risks for Clients who are likely to need Intervention. Describe the foreseeable risk, if there is one (i.e. what specific behaviours have occurred); Is the risk potential or actual? (i.e. has this happened before?); In which situations does the risk occur? How likely is it that the risk will arise? (i.e. how often has it happened before?); If the risk arises, who is likely to be injured or hurt?
HighMediumLowNone
For the safety of the clients, does support, in your opinion, need to be on a one to one basis? Or one staff with two clients? Or one staff with three clients? Your assessment here, will of course, be taken into account, when our Manager consider all available information. (Managers' assessment of appropriate Group size may differ to your view, as they assess knowing how we work at Live a little, and take into account many other variables).

One to one (One staff member with this Client)One to two (One staff member with two Clients)One to three (One staff member with three Clients)Two to one (Two staff members with one Client)Other
If 'Other' please state:
Notes
Please let us know if there is any changes in information we should know to be able to support client, example medication, behavioral changes, upset ETC.
Finally, how did you hear about us?
Should be Empty:

New Client Joining Form

Contact Information

Care & Health Information

Risk Assessment

Notes