NDIS Intake Form

NDIS Intake Form

Includes required fields*
Form Submission Date
Participant Details
Participant First Name:
First name
Participant Last Name:
Last Name
Participant Name*

First NameLast Name
Participant Birth Date

DayMonthYear
Participant Phone Number
Note: Participant phone number only. For contact/nominee/service coordinator details, please enter in relevant section below, otherwise, leave blank.
Participant Email
Note: Participant email only. For contact/nominee/service coordinator details, please enter in relevant section below, otherwise, leave blank.
Participant Address*

Street Address

Street Address Line 2

CityState

Post Code
Living Arrangements:
Language spoken at home:
Interpreter Required:

YesNo
Do you identify as:

AboriginalTorres Strait IslanderNot ApplicableOther
COVID-19 Vaccination Status: *
Is participant under the age of 18 years of age, under guardianship or in the care of family or caregivers?*

YesNo
Contact/Guardian Name:

First NameLast Name
Relationship to Participant:

ParentKinship Carer (e.g. Grandparent, aunt/uncle, sibling)Foster CarerGuardianOther (please specify)
Contact/Guardian Address (if different from participant):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a Guardianship and/or Administration order in place?*

YesNo
Guardian Name:
Guardian Phone Number:
Guardianship E-mail:
example@example.com
Guardianship Type:
Primary Contact
Relationship to Participant:*

Self (participant)Service CoordinatorNomineeCarerFamily MemberGuardianAgencyOther (please specify)
Primary Contact Name:

First NameLast Name
Primary Contact Phone: *
Primary Contact E-mail *
example@example.com
Agency/Coordinator of Service
Referral Agency
Name of referring agency (if applicable)
Coordinator of Supports:

First NameLast Name
Coordinator Contact Number:
Mobile or landline
Coordinator E-mail Address:
example@example.com
Other Service Providers currently engaging:
Disability/Diagnoses/Support Requirements/Notes:
Previous Assessments or Interventions (if known):
Are there restrictive practices in place:*

YesNoUnsure
Chemical Restraint (please provide details):
Environmental Restraint (please provide details):
Mechanical Restraint (please provide details):
Physical Restraint (please provide details):
Seclusion (please provide details):
Any notes (if required):
NDIS Funding and Support Requirements
NDIS Number:*
8 characters in length
Copy of NDIS Plan Available:

YesNo
Plan Start Date*

DayMonthYear
Plan End Date*

DayMonthYear
Funding Type:*

NDIS ManagedSelf-ManagedPlan Managed
Has participant been migrated to the PACE system?*

YesNo
PACE Endorsement:

All participants with Specialist Disability Accommodation and Behaviour Support will need to record their participant-endorsed providers for these two categories in their plan. Specialist Disability Accommodation and Behaviour Supports are required to be delivered by a registered provider under NDIS Commission rules.

By endorsing a provider, you are letting us know the provider can make claims and receive payments for their valid claims on your Agency-managed funds.

You can endorse a provider at any time by talking to your myNDIS contact or by calling the National Contact Centre on 1800 800 110.

As Behaviour Support is a stated support, Healthstyles Clinic requires endorsement as Participants Endorsed Providers/Behaviour Specialists by the Nominee or Coordinator prior to commencing.

Please note: ensure when endorsing that it is as 'Participant Endorsed Providers' as well as 'Behaviour Specialists'.

Healthstyles Clinic Organisation ID: 405 015 1727

Provider name: HEALTHSTYLES CLINIC PTY LTD
If self-managed/plan managed, please provide details for invoices below:
Plan Manager Name/Agency:
Billing E-mail:
example@example.com
Additional details (if required):
Service Required (choose one or more)*

Behaviour Assessment & Plan - A behaviour specialist will be engaged to complete assessment, offer training, and complete a report based on behaviours of concern listed in the referral.Assessment e.g. Cognitive, Screen - A psychologist or behaviour specialist will be engaged to conduct an assessment using standardised assessments tools to identify needs.Early Childhood Intervention - The Allied Health Specialist will be engaged to complete a support plan for individuals aged between 0-7 years.Therapy/Counselling - A member of the The Allied Health team (Social Worker or Psychologist) will be engaged to complete a therapy program with the participant to address their presenting concern.
Line Item*
NDIS Goals and Aspirations:
Service Agreement

Please note: Service Agreement is required to be completed at or prior to commencement of services, and that the initial engagement is covered by the consents below.
Who will be signing the service agreement?*

ParticipantPrimary ContactOther (please provide contact details)
Consent
Has Healthstyles Allied Health Clinic been granted consent to engage in services:*

YesNo
Has Healthstyles Allied Health Clinic been granted consent to complete a service booking:*

YesNo
Has consent to share this information with Healthstyles been obtained from the participant?*

YesNo
Does the participant consent to the use of telehealth in place of face-to-face services where appropriate?*

YesNo
Supporting documents:

Plans, reports, logs, request for service etc
Cancelof
Should be Empty:

NDIS Intake Form

Participant Details

Primary Contact

Agency/Coordinator of Service

NDIS Funding and Support Requirements

PACE Endorsement:

Provider name: HEALTHSTYLES CLINIC PTY LTD

Service Agreement

Consent