NDIS Client Intake Form
-Plan 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
*
First Name
Last Name
My preferred pronoun is:
Please leave blank if not relevant
Phone Number
*
Email
*
Address (Address where you wish for home consultations to occur.)
*
Address one
Address two
City
State
Postal Code
Preferred Contact Method
*
Phone
Text Message
Email
I prefer you to contact...
*
Myself as the Participant directly.
My Support Co-Ordinator
Date Of Birth
*
/
Month
/
Day
Year
NDIS Participant Number
*
When does your current NDIS Plan end?
*
-
Month
-
Day
Year
What type of funding do you currently have available / have budget remaining for?
*
Core
Capacity Building
Both
Back
Next
Who is your Plan Manager?
*
Please enter the company name, phone number and email address, along with the name of any specific person you deal with there.
Who is your Support Coordinator?
*
Please add their company, phone number, email, and any details of a specific person you speak with.
Which of the following days / times may suit for your home consultation/s? Please select all that apply.
*
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?
*
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
*
*Note: Pets must be contained in a separate area of the home or property during home consultations for safety purposes.
Are there any entry or exit points of your home that cannot be accessed or used safely? Please select one.
All inaccessible - I cannot enter or exit my home at all unless I move a significant amount of clutter.
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.
*
Yes
No
Unsure.
What would you like to accomplish by collaborating with me in your home?
*
When thinking about the spaces in my home, my priorities are: Please select all that apply.
*
Decluttering/Organising and Tidying
Aesthetics (I would like to achieve a certain look, style)
I would like assistance with these areas of my home: Please select all that apply.
*
Adult Bedroom
Bathroom/Ensuite vanities and Linen closets
Child/s bedroom
Garage
Garden shed.
Home Office
Kitchen/ Pantry
Laundry/ Mud Room /Entryway
Living/ Dining
Rumpus or Activity Room
Wardrobes/dressers
The area I wish to start with is:
How often do you are items removed from the home via selling, donations, giving away or discarding? Please select one.
*
Once a week.
Once a month.
3-4 times per year.
Never (or you cannot recall the last time this happened)
Which of the following factors have contributed to the current state of your home? Please select all that apply.
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.
Moving house frequently or recently.
Neurodiversity, including ASD, ADHD, SPD, etc.
Physical or intellectual disabilities.
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.
All of the above
Please share (within your comfort level) a little bit about your neurodivergence or disability so that I can understand how we can best support you.
*
I understand that Jodi Maree Interiors is not a Registered NDIS Provider and operates as an Un-Registered Provider. Jodi Maree Interiors complies with all NDIS Guidelines and the NDIS Code of Conduct.
*
Yes, I understand.
No - Please contact Jodi Maree on 0268848090 before proceeding.
Who has completed this form?
*
I am the NDIS Participant
I am the Participant's Support Coordinator
Submit
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