NDIS INDIVIDUAL INTAKE FORM (RECIPIENTS)

  • Version 3.0 - January 2024

  • NDIS INDIVIDUAL INTAKE DOCUMENT

    This document is to be used in the initial interview with the recipient.

  • Agreement to Proceed - NDIS Recipient

    It is imperative to let the new recipient know that they will need to enter into a NDIS Service Agreement which will need to be signed. Explain the service agreement and show the agreement to the recipient and/or their representative.

  • **Note – Should recipient not wish to sign service agreement, selectability cannot offer supports**

     

    Ask the recipient if they wish to proceed and engage selectability as their service delivery provider, having received information about the services we can provide. 

     

  • Has the recipient agreed to proceed?*

  • If at this stage in the consultation, it has been identified that the services required by the recipient are not available through selectability, refer the recipient to the NDIS Local Area Coordinator (LAC) – eg Feros Care.

    Useful resources for the recipient :

    -          https://www.feroscare.com.au/ndis 

    -          https://www.ndis.gov.au/document/finding-and-engaging-providers/find-registered-service-providers.html 

  • Has the recipient been referred to the LAC for further assistance?

  • Recipient Information/Demographics and Preferences

    Please complete the remainder of the intake once the recipient has agreed to proceed.
  • Source of referral
  • Date*
     - -

  • Referred Program - NDIS Recipient

  • Requested service*
  • NDIS Plan Funding Management*

  • Recipient Details

  • Do you need an Interpreter?*
  • Do you have an interpreter ?*
  • Do you need help completing this form*
  • Date of birth*
     - -
  •  -
  • Next of kin*
  •  -
  • Add another next of kin?
  •  -
  • Emergency contact*
  •  -
  • Add another emergency contact?
  •  -
  • Does the recipient have a representative / legal decision-maker?*
  •  -

  • Nominee Details

  • Nominees often have important information that they can share with us which will assist selectability to provide you with personal support services. 

     

    This section gives you the opportunity to identify individuals who you would like to be involved in your care.

     

    Please nominate the person or persons that we can include in discussions about the personal services that selectability will be providing.

     

    Personal and non-personal information = you allow us to discuss anything with this person relating to you and the services you will be receiving, including, but not limited to, thoughts, feelings, your history, your treatment, support, care plan and medications.

     

    NB: without listing a nominee, selectability will be unable to disclose personal or private information about you or your supports to anyone other than you.

     

    By listing a nominee or nominees, this provides selectability permission from you to discuss your personal, private and confidential information with those person/s that you have nominated.

  • Does the recipient have a nominee/s?

  • If yes, please fill in Nominee name and contact details below:

  • Employees will check with you on a regular basis to see if you would like to change the nominations you have made at our quarterly reviews.

    If you would like to change the nominated carer during your admission or care, please see the team or call our office.

  • Recipient Details Continued

    Including living arrangements
  • Sex recorded at birth?

  • How do your describe your gender?

  • Sexual Orientation (check all that apply):

  • Culture/Ethnic/CALD (please tick all that apply):

  • Do you consider yourself to be spiritual?

  • Select one of the following living arrangement options:*

  • Please state if you live:*

  • *Advise the recipient that we will need to undertake a Work Health and Safety Assessment of their home to ensure it is healthy and safe for both the recipient and their workers*

  • Involved community supports/agencies

  • Please provide names of the following providers along with their contact details, if applicable:

  • Has the consumer provided their Positive Behaviour Support Plan?*
  • If yes, does your Positive Behaviour Support Plan have restrictive practices in place?*
  • If yes, may we have a copy?*

  • Consultation - NDIS Recipient

  • Discuss in detail:

    -          The service delivery supports available through selectability (refer to the selectability welcome booklet)

    -          Costs involved

    -          The role of the Individual Service Agreement (ISA) (use the Easy-to-Read Guide available on Sharepoint about the ISA, if necessary)

  • Are there any other service providers currently delivering supports through the recipients NDIS budget/plan?*
  • Has the recipient provided their Positive Behaviour Support Plan?*
  • If yes, does your Positive Behaviour Support Plan have restrictive practices in place?*
  • If yes, may we have a copy?*

  • Agreement to Proceed - PROGRAM Recipients

    Ask the recipient if they wish to proceed and engage selectability as their service delivery provider, having received information about the services we can provide.
  • Has the recipient agreed to proceed?*
  • Have you discussed and been advised of your and selectability's rights and responsibilities?*
  • Have you discussed and been advised on how you can provide feedback?*
  • NDIS plan start date
     - -
  • NDIS plan expiry date
     - -
  • Select one of the below:*
  • Please confirm the below:*
  • Have you discussed and been advised of your and selectability's rights and responsibilities? (can be found in welcome booklet)*
  • Have you discussed and been advised on how you can provide feedback?*

  • Support Worker Preferences

  • Please select preferences:
  • Worker to speak recipient's first language?

  • Shift Preferences - PROGRAMS

  • Preferred Days of the Week:

  • Shift Preferences - NDIS

  • Preferred Days of the Week:

  • Discussion of Recipient Rights

    The following forms can be provided for the recipient to read and review before signing. These documents can be copied and provided back to the recipient when provided a copy of their ISA (Individual Support Agreement) and a copy of the ISP (Individual Support Plan).

  • What does this mean?

    selectability collects personal and other information from you to help us determine whether we can provide the services you need.

    As a person that we support, selectability will also collect and use your information to help us develop and improve the quality of our services.

    If you do not consent to selectability collecting and using your information, selectability will not be able to assist you with the services you have requested.

  • Consent to collect and use your information

    selectability aims to protect the privacy and secure storage of your information. You can view our Privacy Policy on our website www.selectability.com.au or request a copy of our Privacy Policy, which includes information about the collection, use and disclosure of your information.

  • When we need to pass on your personal information

    Your personal information will be kept private and confidential however, there may be times when selectability considers they have a legal obligation to share your information with third parties if:

    • You are likely to harm yourself or another person;
    • A child may be at risk of sexual, physical or emotional abuse, or neglect;
    • There has been a criminal act that has been committed
    • Failure to disclose the information would place you or another person at serious and imminent risk (e.g. emergency)
    • selectability is required by law to release your information (e.g. your records are subpoenaed by a court of law).

  • Marketing information

    In some circumstances selectability may want to use your personal information (such as your contact details) to send you newsletters or promote other services that relate to the service being provided to you by selectability.

    You have the right to ask selectability not to use your information to send you newsletters or promotional information.

    If you do not want selectability to use your information to promote products or services that are related to the services that you receive from us, please let us know below. 

  • Consent to receive marketing

  • Information release to help you

    On occasions selectability may need to contact and/or exchange information relating to your services with other service providers, organisations and agencies.  

  • Please select from the list below services we can speak to with your permission:

  • Recipient consent: 

    By signing this consent form you authorise selectability to use, store, release and exchange your information with your lifestyle support workers, other service providers, health and medical practitioners and other government agencies as stated above, to support the services we provide to you and to comply with selectability’s legal obligations. I understand I can access selectability’s privacy statement via their website – www.selectability.com.au.
     
    I consent to selectability collecting and using my information for the purposes outlined above for providing services to me and to help improve the quality of their services.

     

  • Date*
     - -
  • Recipient has agreed to the above and has offered verbal approval, rather than signature*
  • Does the recipient have a legal representative?*
  • Date*
     - -
  • Indicate below if decision maker is the Office of Public Guardian:*

  • Release for Use of Images or Recordings

    For general publishing or on selectability social media and selectability website
  • I give consent to selectability to use and retain an image or recording as detailed below that may identify me. I understand that once my image has been posted via social media it can be taken down; however, may remain on the virtual network.
  • (Optional) So that your image is used in the appropriate context, do you identify as:

  • I consent to the following:

  • Subject to any considerations above, I understand that by giving consent, selectability can use the image/recording to promote their activities. selectability may reproduce the image or recording in any form, in whole or in part, and distribute the works by any medium including printed, the internet, CD-ROM or other multimedia.

    I understand that selectability:

    • will not pay me for giving this consent or for the use of my image or recording
    • will return or destroy images or recordings if I withdraw this consent; and
    • will not infringe the rights of any third party by exercising its rights given in this consent

    Recipient details:

    For the purpose of this consent form, the person whose images or recordings are used is known as "the recipient".

  • Recipient has agreed to the above; however, has offered verbal approval, rather than signature*
  • Indicate below if decision maker is the Office of Public Guardian:*

  • Recipient Needs, Interests, Achievements and Goals

    Please involve the client/consumer/participant/recipient in this discussion to collect information in order to support them.

  • Needs - (Communication & Disability)

  • Recipient's communication needs/abilities:*


  • Diagnosis/Diagnoses:*

  • Does the Recipient utilise assistive technology?*
  • Does the recipient have a hearing impairment?*
  • Does the recipient have a visual impairment?*
  • Does the recipient need assistance with the following:*

  • Mobility and Personal Support Needs (Physical)

    Ask recipient/representative for self assessment
  • Walking*
  • Emergency Evacuation*
  • Bathing*
  • Transfer to bed/toilet/wheelchair/vehicle/other*

  • Needs - (Health)

  • Is a medical management plan or mealtime management plan required? If so, has this plan been provided to the recipient or other stakeholders and are they able to share a copy with selectability? (We cannot commence service until we have a copy of the treatment plan)*
  • Does the recipient have alcohol and/or drug use history? (If recipient has Identified current substance use, please explain selectability policy and procedure around Duty of Care and Support)*
  • Does the recipient have a treatment authority?*
  • If Yes, can we obtain a copy?*
  • Does the recipient have one of the following management plans? (please provide)*

  • BOOK IN AS SOON AS POSSIBLE WITH GENERAL PRACTITIONER 

     

  • OR

  • Does the recipient require one of the following management plans?*

  • Have you advised the recipient of the risk involved with not providing a medical management plan?
  • Does the recipient require medication prompting, assistance or administration? (SIL and 24/7 care only)*

  • K5

    The following five questions ask about how you have been feeling in the last four weeks. For each question, select the option that best describes the amount of time you've felt that way.

  • Please note, if this is being completed for a recipient that is referred by QLD Health (eg. selectwellbeing) it is mandatory to attempt this under the requirements of QLD Health

  •    
  •    
  •    
  •    
  •    

  • Scoring:The K5 Total score is based on the sum of K5 item 01 through to 05 (range: 5-25). If any item has not beencompleted (that is, has not been marked 1, 2, 3, 4, 5), it is excluded from the calculation and not counted as a valid item. If any item is missing, the Total Score will not be achieved.

    Minimum possible score of 5 and maximum possible score of 25. Low scores indicate low levels of psychologicaldistress and high scores indicate high levels of psychological distress.

    􀁸 low/moderate 5-11

    􀁸 high/very high 12-25

    􀁸 not completed/invalid.

  • Individual Care Plan - (Behaviours)

    In line with the selectability service delivery manual the Individual Care Plan is to be used to undertake an assessment of individual needs of the recipient being supported so that these needs are being appropriately addressed and responded to within our capability. The Individual Care Plan is to be made accessible to all Lifestyle Support Workers to provide them with valuable information before providing a service to the recipient.

  • Individual Support Plan - how selectability will support you to achieve your goals

    Recipient’s identified recovery support needs and goals: e.g. – Increasing social and community participation by exploring areas of interests/vocational aspirations/travel/friendships/family relationships/independence & self-care/confidence/budgeting and saving/health etc.

  • Emergency Disaster Assessment

    Communication

  • In the event of an emergency/disaster who does the recipient identify as their trusted person for helpful information? 

  • Management of Health In The Event of An Emergency or Disaster

  • Confirmation

    I have discussed the following topics with my selectability support provider during this meeting:
  • Completed (tick box):*

  • When I sign this form, I am saying that this is a form with; my plans, consent to use personal information with selectability, chosen nominee/s and selected agency/s, that I had full input into and have agreed to as a plan for myself and selectability to work on together.

    I know that I will be able to revisit this plan and my consents whenever I want, to add or change parts as my needs and goals change.

  • Date*
     - -
  • Recipient has agreed to the above and has offered verbal approval, rather than signature*
  • Does the recipient have a legal representative?*
  • Date*
     - -
  • Date*
     - -
  • Next Review Date/Month:
     - -
  • Completed (tick box)

  • WHS Assessment

    Permission for Work Health & Safety Check - Recipient's Home

  • Work Health and Safety Assessment Checklist – Recipient’s Home

    What does this mean?
    As per the Work Health and Safety Act 2011 selectability must ensure, as a primary duty of care, the health and safety of all workers and the people we support as well as the place that they work “the workplace” is safe. As the workplace in this instance is actually your home – we must inspect it for safety issues.


    Your permission
    selectability requests your permission for our workers to undertake an assessment of your home and complete the checklist below. The process will also ensure any areas that you may need to address to ensure there is no risk to your own health and safety.

    In addition, we would like to ask some questions about things that stress you so that we can ensure our workers provide supports for you so that your emotional safety and theirs is supported.


    Safety report findings
    We will provide a report back to you about our findings bringing any issues to your attention that needs fixing.

     

    I agree for a workplace health and safety inspection and discussion to occur

     

  • Recipient has agreed to the above and has offered verbal approval, rather than signature*
  • Date*
     - -
    • Please note if providing Community Access support - only the ‘outside the residence’ section should be completed.
    • For – in home care please complete whole assessment (relevant fields that workers will be accessing).

  • Work Health and Safety Assessment Checklist - Recipient's Home (please read the following/paraphrase to the recipient)

  • As the ‘workplace’ in this instance is actually your home – we must inspect it for safety issues. Thank you for providing permission to inspect it – we will provide a report back to you so that you will also know what areas of the home may provide any problems to you or your workers/s so that it can be addressed to ensure risk to health and safety is minimised.        

  • Date of inspection*
     - -

  • Outside the residence
  • Is it safe for selectability employees to park their vehicle on the street in front of the house?*
  • If there is a gate, is it easy to open and close?*
  • Is the pathway from the vehicle to the house safe? (eg: steps, ramps, railings, overgrown vegetation, trip hazards)*
  • Are there any pets at the residence?*
  • Is there a safety switch on the switchboard?*
  • Are doorways clear, free from obstruction and easy to open and close?*
  • Are there any other hazards presented outside the residence and on entry?*

  • PLEASE INDICATE LEVEL OF ACCESS TO RECIPIENT'S HOUSE

  • *

  • Inside the residence

  • GENERAL - Are the following safe?

  • Floor surface (level & smooth)*
  • Hallways (level & uncluttered)*
  • Power points*
  • Electrical Cords*
  • Temperature / Humidity*
  • Lighting*
  • Easy exit*
  • Hygiene of furniture*
  • Smoke detectors are installed*

  • KITCHEN-Are the following safe?

  • Work heights are suitable*
  • Seating available for meal preparation assistance*
  • Floor surface (level & smooth)*
  • Electrical equipment and power points*

  • LAUNDRY-Are the following safe?

  • Location of washing machine*
  • Floor surface (level & smooth)*
  • Electrical cords*
  • Waste bin/basket for soiled items*

  • BATHROOM-Are the following safe?

  • Access to shower, bath, toilet*
  • Floor surface (level & smooth)*
  • Electrical equipment & cords*
  • Water temperature easy to control*
  • Ventilation*

  • BEDROOM-Are the following safe?

  • Floor surface (level & smooth)*
  • Power points & electrical leads:*
  • Uncluttered*
  • Ventilation*

  • MANUAL TASKS

  • Can you work without excessive bending, twisting or over-reaching?*
  • Is the recipient, due to mobility issues, awkward to handle, unstable or unbalanced?*
  • Does the recipient utilise any equipment? (e.g.wheelchair, oxygen)*
  • Is there a safe method for transferring the recipient up and down the stairs?*
  • Is there a safe method to transfer the recipient in/out of the vehicle where required?*
  • Is there equipment available to assist with the transferring of wheelchairs / wheelie walkers in/out of the car where required?*
  • Is there a safe method for assistance in showering/toileting etc?*

  • ANIMAL CARE

  • Please note employees are unable to access your home when you are away so staff are unable to provide this care service for animals.

  • Important Questions

    Please work with the recipient to respond to the below questions

  • SMOKING

  • Is there anyone in the household who smokes?*
  • Has it been explained to the recipient that the LSW has the right to leave and go outside while the recipient or other persons are smoking?*
  • Recipient has agreed to the above and has offered verbal approval, rather than signature*

  • DRINKING

  • Is there anyone in the household who drinks alcohol?*
  • Has it been explained to the recipient that the LSW has the right to end shift if the recipient is drinking/under the influence?*
  • Recipient has agreed to the above and has offered verbal approval, rather than signature*

  • DRUG TAKING

  • Is there anyone in the household who takes drugs?*
  • Has it been explained to the recipient that the LSW has the right to end shift if the recipient is taking drugs/under the influence?*
  • Recipient has agreed to the above and has offered verbal approval, rather than signature*

  • OTHER ISSUES/HAZARDS OR RISKS

  • Were any risks identified during the WHS assessment?*

  • PLEASE NOTIFY YOUR LINE MANAGER OF ANY RISKS IDENTIFIED PRIOR TO ON-BOARDING

  • selectability Employee acknowledgement

  • I have conducted this assessment to the best of my ability. I have identified and notified the individual of any hazards. (Team leader to provide a written report for action items to recipient)

  • Date
     - -
  • Date
     - -
  • Date*
     - -
  • Hazard identified in TRACCS*
  • Date*
     - -
  • Family / carer characteristics*
  • Individual characteristics*
  • Protective factors*
  • Tick all that are completed:*
  • Date
     - -

  • FORM COMPLETION

    Please press the submit button below to finish and submit this form.
  • Should be Empty: