MADE TO HELP INTAKE FORM

MADE TO HELP INTAKE FORM

version 16042026
Link to download New Client Intake Questionnaire and then please attach to this form or fill in the below information
MTH WORKER PLEASE DOWNLOAD THE FORM.

SAVE TO CLIENT FILE, before filling in any information, thank you.

This form provides online choice and control for Participants. In order to save this from please place an answer in the box, as it will not save without an answer.

If the question does not apply to you, please type 'N/A' in a box, thank you.
Description of your request
What kind of supports do you need?
Support Coordinator
Participant's Name
Participants NDIS Number
Plan Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Plan End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Funding: NDIS, Plan Managed or Self Managed
Plan Management Company
Enter NA if not applicable
Participants Contact Number
Particpants Address
Participants Email Address
example@example.com
Particpants Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Country of Birth
Next of kin or Emergency contact
Next of Kin OR Emergency - Email contact details
example@example.com
Next of Kin OR Emergency - Phone Number
NDIS Plan Nominee (if you have one in place?)
Is mealtime management required? Do you have any swallowing or eating issues?
If participant requires mealtime management please complete

Mealtime management form
Do you have frequent hospital admissions?
If participant requires hospital admissions please complete

Transitions form
Is the Participant in Departmental Care or has a Guardianship Court Order?
If Yes, Name of Guardian
Contact Number
Does the Participant have an Advocate?
Yes/No
If, Yes, Name of Advocate
Contact Number
What language(s) does the participant speaks
Do they need an Interpreter to attend Interviews?
Interpreter Service preferred
Contact Number
Please list any cultural preferences you may have eg; Full dress, Gender Preference for services etc
Is the Participant from Aboriginal or Torres Strait Islander descent? Yes/No
If, yes do they have a Case Worker? Yes/No
Contact Number for Indigenous Service Provider
Please tell us about your preferences for services, including your Likes and Dislikes, Activities required?
Are there any Occupational Health and safety concerns at your property? (Please indicate here and you will be asked to fill in a Home Safety Assessment of your home with your Support Coordinator)
Do you have a copy of the NDIS Plan?
Do you have a copy of the NDIS Plan?
What are your NDIS Goals you want to work on?
Upload NDIS Plan

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Do you have a medication plan?
Upload medication plan (if available)

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Do you have any allied health plans? eg; Epilepsy, Asthma and Diabetes management Plans ?
Upload allied health plans? eg; epilepsy, Asthma and diabetes management plans ?

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Upload Plan and any other relevant documents

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Part of being a NDIS client, NDIA have requested all clients hold evidence of a current Risk and Emergency Plan and Support Plan which needs to be conducted on an annual basis.

You will be asked to formulate this with your Support Coordinator, after onboarding with Madetohelp PTY ltd, thank you for your cooperation.

Where did you hear about Made To Help?

Rows	YES/NO	Comments
A friend, family member or colleague
Made To Help website
Social Media
Referred from a provider, which one?
Community notice boad, which one?
Other

Date Form Completed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Completed By
Phone Number of Person Completing Form
Signature
Should be Empty: