NDIS Client Intake Form
-Self Managed
Instructions
Complete this intake form or ask your Support Co-Ordinator to assist you to do this.
An In-home consultation will be organised. If you would like to proceed we will organise a date and time to attend your home.
Invoices will be sent to your Plan Manager for payment and before/after photographs may be submitted to validate work.
Name
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First Name
Last Name
Email
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Address (Address where you wish for home consultations to occur.)
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Address one
Address two
City
State
Postal Code
Phone Number
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Format: (000) 000-0000.
Which of the following days / times may suit for your home consultation/s? Please select all that apply.
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Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Which of those days / times are your most preferred?
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Please share who lives in your home or others that may be present during consults. This includes family members, household staff (e.g., a cleaner) and pets.
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*Note: pets must be contained in a separate area of the home or property during home consultations for safety purposes.
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Are there any entry or exit points of your home that cannot be accessed or used safely (without tripping over or moving clutter out of the way)? Please select one.
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All inaccessible - I cannot enter or exit my home at all unless I move a considerable number of items.
Most inaccessible - you only have ONE entry or exit that is useable due to the clutter.
Some inaccessible - some are blocked, or we would need to move some items to use them.
No - all entries and exits can be used safely, without moving anything out of the way.
Are your smoke alarms currently working with batteries changed regularly? Please select one.
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Yes
No
Unsure.
What would you like to accomplish by working with me in your home?
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When thinking about the spaces in my home, my priorities are: Please select all that apply.
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Decluttering
Organisation
Aesthetics (you would like to achieve a certain look, style)
I would like assistance with these areas of my home: Please select all that apply.
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Adult Bedroom
Bathroom/Vanity
Child/s bedroom
Clothes Wardrobe/Dresser
Garden shed
Garage
Home Office/Study
Kitchen/Pantry
Laundry/Mudroom
Living/Dining
Rumpus or Activity room
The area I wish to start with is:
Which of these do you feel most contributes to clutter in your home? Please select one.
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Too many items coming into the home frequently.
Items rarely or never being removed from the home?
All of the above.
When items are brought into your home, they are: Please select all that apply.
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Purchased or obtained by you.
Purchased or obtained by another person living in my home.
Given to us by family or friends as gifts or hand me downs.
How often do you remove items from the home via selling, donations, giving away to someone you know or on "freebie" type groups, or discarding damaged items? Please select one.
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Once a week.
Once a month.
3-4 times per year.
Never (or you cannot recall the last time)
Which of the following factors have contributed to the current state of your home? Please select all that apply.
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Busy or unable to find time.
Growing up in a cluttered or hoarding environment.
Mental health challenges, including depression, anxiety, PND/A, bi-polar, PTSD, etc.
Moving house frequently or recently.
Neurodiversity, including ASD, ADHD, SPD, etc.
Physical or intellectual disabilities.
The item is on trend or fashionable and I want to keep up with my social circle.
Unsure where to begin.
We have welcomed a family member to the home, e.g., new baby, young adult returning home or elderly relative moving in.
Submit
Should be Empty: