HDS Participant Intake Form

Communication Preferences
What is your preferred method of communicating with HDS? (select more than 1 if required)

Phone CallEmailText MessagePost (letters)Face to faceThrough my advocateEasy Read GuidesOther

Your Goals
In addition to your goals listed in your NDIS plan, what are your goals for your time with HDS?

Risk Assessment

This section requires you to disclose any significant risks that may relate to your supports requested.
Please list any risks identified, relevant to your supports
Risk severity
If you are receiving supports under 0107 - Daily Activities, please tick all that apply below:

receive supports in your home;do not regularly receive face-to-face supports from other NDIS providershave limited regular contactwith relatives, friendsor a support network;depend on equipment or another person to assist with their physical mobility;depend on anotherperson to assistwith communication;depend on equipmentto facilitate communication or the use of communication devices.

Your Decision Making - Informal

This section asks about your advocate, family member, friend etc. (NOT Formal Guardian)
Do you receive any help with your decision making?

YESNO - go to the next page
If Yes, what are their details?

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship with you
Email
example@example.com

Guardianship Functions

This section asks about details of any formal guardianship orders you have in place
Do you have a Formal Guardian*

YESNO - go to the next page
If Yes, what are their details?

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What function does your guardian have?

Restrictive PracticeMedical / DentalHealthcareAccomodationServicesOther decision making functions

Financial Management

This section asks about details of any formal financial management you have in place
Is there anyone that provides your financial management ie. TAG?

YESNO - go to the next page
If Yes, what are their details?

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

NDIS - Coordination of Supports

If you have a current Coordinator of Supports, please record their details below
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Completing this form
Did you require assistance completing this form?

If so, please record the details of the person whom completed it.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Role of this person
Should be Empty:

	Fully Dependent	Requires some support	Fully Independent
Housework
Toileting
Transport
Shopping
Eating
Meal Prep
Money Management
Communication
Taking Medication
Emergency management
Climbing stairs
Following a routine
Making friends / relationships
Transfers
Accessing the community
Personal Care
Managing Behaviour
Walking
Maintaining home / yard

Intake Form