New Client Form

New Client Form
Participant Details
Title/Pronouns (eg, he/she/they)
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
NDIS Number*
Address*
Phone
Type of living arrangement*
Parent / Carer / Representative details
Name*

First NameLast Name
Relationship to Participant*
Email*
example@example.com
Mobile phone number*
Would you like to be the official next of kin for all contact and in case of emergency?*
If no, please specify next of Kin with contact details:*
Details of Support Coordinator (if applies)
Medical History

Please list formal diagnosis/diagnoses of participant below (if applicable, please also include mental illness) Please write 'none' if participant has no medical history to report:
1.*
2.
3.
4.
5.
6.
Epilepsy? Please provide further detail if applicable (e.g. triggers, management plan etc):*
Dietary Requirements? Please provide further detail if applicable (e.g. nut allergy, gluten intolerence etc):*
Allergies? Please provide further detail if applicable (e.g. triggers, management plan etc):*
Please specify as appropriate if there will ever be a requirement for staff to either administer medication or prompt the participant to take their medication:*
Name three activities the participant would enjoy attending (eg. beach walk, sport, music, cooking etc):
Is there any further information you would like us to know regarding the care and safety of the participant?*
Funding
Type of NDIS Plan*
Please send any services invoices to (type either the email address to plan manager (plan partners) or parent directly):*
example@example.com
Privacy Policy
Privacy information: To provide a high standard of support / care we need to collect personal information fromour participants and those acting on their behalf. At times this information may need to be shared with other support workers / staff within our organization (acting in the best interests of the participant) or we may be legally bound to disclose information. All persons acting with the information listed above are bound by confidentiality. Please do not hesitate to discuss any concerns or questions about anything related to privacy and handling of this information with program directors Andrew Lozanovski and Josh Beare or with the General Manager Elise Whitby.

I acknowledge that Community Care Collective and our service providers will collect your personal and health information to enable us to safely provide the highest level of disability support and care and to optimize safety protocols for the delivery of our service I consent to the handling of this personal information within Community Care Collective as an organization

I agree Client / participant signature (or parent / guardian signature if acting on behalf of the participant):
Please print name*
Date*

MonthDayYear
Date
Type of living arrangement
Should be Empty:

New Client Form

Participant Details

Parent / Carer / Representative details

Medical History

Funding

Privacy Policy