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.
Recipient Information/Demographics and Preferences
Region*
Source of referral

selfrepresentativelegal decision-makerother
Source of referral*
Please specify details of referrer below: *
Please indicate whether this is a PROGRAMS or NDIS recipient?*

NDIS recipient - Service DeliveryNDIS recipient - Supported Independent Living
TRACCS record ID
NDIS reference number (if applicable)
Date*

DayMonthYear
Date
Recipient Details
Full name*

First nameMiddle nameLast name
Preferred name*

First nameLast name
Do you need an Interpreter?*

YesNo
If 'yes', which language
Do you have an interpreter ?*

YesNo
Name

First nameLast name
Do you need help completing this form*

YesNo
Name:
Relationship
Date of birth*

DayMonthYear
Date
Country of birth
Contact number

Area codePhone number
Email address
example@example.com
Residential and postal address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next of kin*

YesNo
Next of kin full name

First NameMiddle NameLast Name
Next of kin contact number

Area CodePhone Number
Next of kin email address
example@example.com
Add another next of kin?

YesNo
Next of kin full name (2)

First NameMiddle NameLast Name
Next of kin contact number (2)

Area CodePhone Number
Next of kin email address (2)
example@example.com
Emergency contact*

YesNo
Emergency contact name

First NameMiddle NameLast Name
Emergency contact's number

Area CodePhone Number
Emergency contact's email address
example@example.com
Add another emergency contact?

YesNo
Emergency contact name (2)

First NameMiddle NameLast Name
Emergency contact's number (2)

Area CodePhone Number
Emergency contact's email address (2)
example@example.com
Does the recipient have a representative / legal decision-maker?*

YesNo
If yes, please enter full name of representative / legal decision-maker

First NameMiddle NameLast Name
Relationship
Contact number

Area CodePhone Number
Email address
example@example.com
Residential and postal address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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?

YesNo
If yes, please fill in Nominee name and contact details below:
Nominee details*
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 has agreed to the above and has offered verbal approval*

Yes
Recipient Details Continued

Including living arrangements
Sex recorded at birth?

MaleFemaleDo not wish to discloseOther
How do your describe your gender?

ManWomanNon-binary personOther
Sexual Orientation (check all that apply):

Straight/HeterosexualLesbianGayBisexualPansexualQueerAsexualUnsurePrefer not to answerOther
Culture/Ethnic/CALD (please tick all that apply):

AustralianAustralian AboriginalBulgarianChineseEnglishFijianFilipinoHungarianIndianIrishNew ZealanderPapua New GuineanScottishSingaporeanTorres Strait IslanderUnstatedOther
Do you consider yourself to be spiritual?

NoYesOther
Select one of the following living arrangement options:*

Home ownerInstitutional settingNo fixed address - homelessNo fixed address – couch surfingPrivate rentalRental – Department of HousingSIL - Supported Independent LivingShort-term crisisWith relatives/friendsOther
Please state if you live:*

On your ownWith othersWith pets
If living with others/pets: name and relationship, name and animal:*
*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:
Aboriginal and Torres Islander support
CALD support
Community mental health case worker
Doctor (GP)
Employment provider
Financial support/income
Guardianship (Office Public Guardian)
Legal authorities, probation and parole, Department of Justice
NDIS plan manager
NDIS service delivery
NDIS specialised support coordination
NDIS support coordination
Other government agency
Pharmacist/chemist
SIL package
Specialist providers, private allied health, psychiatrists and psychologists
Other
Referred Program - PROGRAM Recipients
Requested program*
Please tick documents included in referral:

referral formrisk screening toolrecipient care planrecipient case reviewexternal provider consent to obtain and release informationnone provided
Referred Program - NDIS Recipient
Requested service*

NDIS service delivery (core & capacity building)
NDIS funding management*

NDIA managedSelf-managedPlan managed (please specify provider below)
Details:
Establish with the recipient, if they have tested eligibility for NDIS or already started this process.

If they have, please take note of the current stage they are at in the application process. If not, use this opportunity to advise them about NDIS and the support selectability can provide if this is something they wish to explore.
Consultation - PROGRAM Recipients
Discuss in detail:

-          The service delivery supports available through selectability

-          Costs involved or how funding is accessed

-          Other permissions etc
Establish with the recipient, if they have tested eligibility for NDIS or already started this process.

If they have, please take note of the current stage they are at in the application process. If not, use this opportunity to advise them about NDIS and the support selectability can provide if this is something they wish to explore.
Add comments:
Have you been provided with a current Positive Behaviour Support Plan? *
Has the consumer provided their Positive Behaviour Support Plan?*

YesNo
If yes, does your Positive Behaviour Support Plan have restrictive practices in place?*

NoYesUnsure
If yes, may we have a copy?*

YesNoN/A
Please specify restrictive practices below if applicable: *
Consultation - NDIS Recipient
Discuss in detail:

-          the service delivery supports available through selectability (refer to the NDIS participant starting my plan website page)

-          costs involved

-          the role of the Individual Service Agreement (ISA) (use the Easy-to-Read Guide about the ISA, if necessary)
Add comments:
Have other agencies provided service delivery supports for this plan?*

NoYes
If "Yes", list the current NDIS budgets?
Have you been provided with a current Positive Behaviour Support Plan?*
Has the consumer provided their Positive Behaviour Support Plan?*

YesNo
If yes, does your Positive Behaviour Support Plan have restrictive practices in place?*

YesNoUnsure
If yes, may we have a copy?*

YesNoN/A
Please specify restricitve practices below if applicable: *
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?*

No (Thank recipient for their time, offer should they wish to discuss selectability services in the future and end consultation meeting)Yes (provide/email consumer selectability Welcome Pack)
Have you discussed and been advised of your and selectability's rights and responsibilities?*

YesNo
Have you discussed and been advised on how you can provide feedback?*

YesNo
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 it to them 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?*

No (Thank recipient for their time, offer should they wish to discuss selectability services in the future and end consultation meeting)Yes - (provide/email recipient with selectability Welcome Pack
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?

No (proceed to Discussion of Recipient Rights section)Yes (end consultation meeting)
If Yes, please provide reasons below and then END consultation meeting
NDIS plan start date
NDIS plan start date

DayMonthYear
Date
NDIS plan expiry date
NDIS plan expiry date

DayMonthYear
Date
Select one of the below:*

Recipient agrees to provide their NDIS plan to selectabilityRecipient agrees only to provide the goals from their NDIS plan to selectability
Please confirm the below:*

Recipient agrees to signing an Individual Service AgreementRecipient does NOT agree (explain conditions of services)
Have you discussed and been advised of your and selectability's rights and responsibilities? (can be found in welcome booklet)*

YesNo
Have you discussed and been advised on how you can provide feedback?*

YesNo
Support Worker Preferences
Please select preferences:

MaleFemaleNo preferenceTo be determined by Team Leader
Desired worker attributes:
Worker to speak recipient's first language?

YesNoNo preference
If yes, please specify preferred language:
Shift Preferences - PROGRAMS
Preferred Days of the Week:

MondayTuesdayWednesdayThursdayFriday
Please specify start and finish times (please use 24-hr clock eg 0800 = 8am; 1700 = 5pm):
Shift Preferences - NDIS
Preferred Days of the Week:

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please specify desired times on chosen days:
Other information:
What are your hobbies/interests?
Do you belong to or enjoy any clubs/groups/sporting activities?
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.
Do you wish to receive newsletters from selectability?
Consent to receive marketing

I do not want selectability to send me newsletters or information about other servicesI want selectability to send me newsletters or information about other services
Establish with the recipient, if they have tested eligibility for NDIS or already started this process.

If they have, please take note of the current stage they are at in the application process. If not, use this opportunity to advise them about NDIS and the support selectability can provide if this is something they wish to explore.
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:

CentrelinkCommunity Mental Health Case WorkerEmergency ContactEmployment ProviderLegal Authorities, Probation and Parole, Department of JusticeNDISOffice of the Public Guardian (OPG)Other Government AgencyQld Department of Communities, Child Safety and Disability ServicesSpecialist Providers, Psychiatrists and PsychologistsSupport CoordinatorTreating DoctorOther
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.
Signature:*

Clear
Full Name*

First NameMiddle NameLast Name
Date*

DayMonthYear
Date
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below
Does the recipient have a legal representative?*

YesNo
Legal representative signature *

Clear
Legal representative name *

First NameMiddle NameLast Name
Date*

DayMonthYear
Date
Indicate below if decision maker is the Office of Public Guardian:*

Yes, they are the decision makerNo, they are not the decision maker
Tick below if decision maker is the Office of Public Guardian:

OPG consent on file
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.

Yes, consent givenNo, consent not given
(Optional) So that your image is used in the appropriate context, do you identify as:

AboriginalTorres Strait IslanderOther
I consent to the following:

selectability website and social mediaselectability Annual General Meeting (AGM)selectability Newsletterselectability media presentationsAll of the above
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 Signature:*

Clear
Date*

First NameMiddle NameLast Name
Recipient has agreed to the above; however, has offered verbal approval, rather than signature*

Yes, verbal approval offeredNo, physical signature provided
Legal representative signature
Legal representative name (optional)

First NameMiddle NameLast Name
Indicate below if decision maker is the Office of Public Guardian:*

Yes, OPG are the decision makerNo, OPG are not the decision maker
Tick below if decision maker is the Office of Public Guardian:

OPG consent on file
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:*

Unable to communicateCan communicate with verbal promptsCan communicate but is difficult to understandUses assistive communication equipmentNo identified communications support needsOther
Main language spoken at home:*

EnglishOther
Diagnosis/Diagnoses:*

Acquired Brain InjuryAttention Deficit Hyperactivity DisorderAutismBipolar Affective DisorderBorderline Personality DisorderCerebral PalsyDementiaDissociative Identity DisorderDown SyndromeIntellectualNeurologicalObsessive-Compulsive DisorderPhysicalPsychiatricSchizophreniaSurgery/Medical ComplicationsOther
Please provide further details on identified diagnosis/diagnoses (particularly for physical, psychiatric or neurological diagnosis - PLEASE IDENTIFY):*
Does the Recipient utilise assistive technology?*

NoYes
If yes then please specify:*
Does the recipient have a hearing impairment?*

NoYes
If yes then please specify:*
Does the recipient have a visual impairment?*

NoYes
If yes then please specify:*
Does the recipient need assistance with the following:*

SittingNavigating stairsStandingWalkingPersonal hygiene (showering/toileting)N/A
Please provide a description of the above:*
Mobility and Personal Support Needs (Physical)

Ask recipient/representative for self assessment
Walking*

IndependentSupervisionAid RequiredUnable to Mobilise
Emergency Evacuation*

IndependentSupervisionAid RequiredUnable to Mobilise
Bathing*

IndependentSupervisionAid RequiredUnable to Mobilise
Transfer to bed/toilet/wheelchair/vehicle/other*

IndependentSupervisionAid RequiredUnable to Mobilise
Notes:
Needs - (Health)
Details of any medical conditions/medical alert or allergies: (eg. epilepsy, asthma, diabetes, swallowing difficulties or dysphasia)*
Is a medical management plan required and if so, has this plan been provided? (We cannot commence service until we have a copy of the treatment plan)*

NoYesN/A
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)*

NoYes
If Yes then please specify:
Does the recipient have a treatment authority?*

NoYes
If Yes, can we have a copy?*

NoYes
Does the recipient have one of the following management plans? (please provide)*

Behavioural Management PlanDiabetes Management PlanDysphasia Management PlanEpilepsy Management PlanIndividual Management Plan for Mental Health and WellbeingSwallowing Difficulties Management PlanNot currently, but requires a management planN/AOther
BOOK IN AS SOON AS POSSIBLE WITH GENERAL PRACTITIONER
OR
Does the recipient require one of the following management plans?*

Individual Management Plan for Mental Health and WellbeingEpilepsy Management PlanDiabetes Management PlanBehavioural Management PlanN/AOther
Has the recipient provided a copy of their medical management plan?*

YesNoWishes not to provide
Have you advised the recipient of the risk involved with not providing a medical management plan?

YesNo
Does the recipient require medication administration? (someone to help with medication)*

NoYesN/A
If Yes, please specify how we can support you:
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

In the last four weeks, how often did you feel nervous?

	1	2	3	4	5

1 is None of the time, 5 is All of the time

In the last four weeks, how often did you feel without hope?

	1	2	3	4	5

1 is None of the time, 5 is All of the time

In the last four weeks, how often did you feel restless or jumpy?

	1	2	3	4	5

1 is None of the time, 5 is All of the time

In the last four weeks, how often did you feel everything was an effort?

	1	2	3	4	5

1 is None of the time, 5 is All of the time

In the last four weeks, how often did you feel so sad that nothing could cheer you up?

	1	2	3	4	5

1 is None of the time, 5 is All of the time

TOTAL
Reason why not completed:
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.
Emergency Disaster Assessment

Communication
In the event of an emergency/disaster who does the recipient identify as their trusted person for helpful information?
Name*
Phone number*
Email
example@example.com
Management of Health In The Event of An Emergency or Disaster
Where has the recipient stated they keep their health information? (If recipient does not know, encourage the recipient to speak with their doctor and / or family)*
How will the recipient identify how they will manage/monitor health/medical treatment in the event of an emergency? (If the recipient does not know, encourage the recipient to speak with doctor and / or family)*
Has the recipient identfied that they are able to adjust any of their supports during an event of an emergency/disaster?*
What does this look like?*
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.
My early warning signs (What should we look out for to know if you are having a bad day or feeling unwell?)*
What makes me upset/have a bad day? (What kinds of things start/cause a bad day or the start of feeling unwell?)*
How do I stay happy and healthy? (What things do you find change your day, make you feel good, relax or de-stress you when you are having a bad day or feeling unwell? e.g. people, places, ideas that specifically help, music, walking, watching videos)*
How can selectability help you to stay happy and healthy? (What can we do to help you when you feel like you are having a bad day i.e. get you out of a crowded room)*
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.
Goal 1*
Strategies on how to achieve goal*
Goal 2*
Strategies on how to achieve goal*
Goal 3*
Strategies on how to achieve goal*
Goal 4*
Strategies on how to achieve goal*
Goal 5*
Strategies on how to achieve goal*
Confirmation

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

Individual Support Plan (ISP)Individual Care Plan (ICP)Rights and Responsibilities (12 monthly)Privacy and Confidentiality Policy (12 monthly)Recipient Feedback Pathway explained
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.
Signed: Recipient *

Clear
Date*

DayMonthYear
Date
Recipient Name*

First NameLast Name
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below*
Tick if applicable

OPG consent
Does the recipient have a legal representative?*

YesNo
Signed: Legal representative *

Clear
Date*

DayMonthYear
Date
Legal Representative Name*

First NameLast Name
Signed: selectability Representative *

Clear
Date*

DayMonthYear
Date
Name*

First NameLast Name
Next Review Date/Month:

DayMonthYear
Date
Tick if applicable

Completed by third party (e.g. Family/Referrer/Guardian)
Name of third party

First NameMiddle NameLast Name
Third party's relationship with recipient
Completed (tick box)

Communication and disabilityHealthFunctional needsSocial/emotional needsStar chartIndividual care planPreferencesInterests/achievements/strengthsGoals/individual support plan
Reason not completed by recipient:
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 name*

First nameMiddle nameLast name
Recipient signature*

Clear
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below*
If decision maker is the Office of Public Guardian

OPG consent on file
Date*

DayMonthYear
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.
Recipient name*

First NameLast Name
Recipient address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of inspection*

DayMonthYear
Date
Outside the residence
Is it safe for selectability employees to park their vehicle on the street in front of the house?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
If there is a gate, is it easy to open and close?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Is the pathway from the vehicle to the house safe? (eg: steps, ramps, railings, overgrown vegetation, trip hazards)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Are there any pets at the residence?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented (eg. restrained):
Is there a safety switch on the switchboard?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Are doorways clear, free from obstruction and easy to open and close?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Are there any other hazards presented outside the residence and on entry?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
PLEASE INDICATE LEVEL OF ACCESS TO RECIPIENT'S HOUSE
Community Access Only - please proceed to remainder of intake formInside residence - please proceed to complete areas of access on WHS form below
Inside the residence
GENERAL - Are the following safe?
Floor surface (level & smooth)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Hallways (level & uncluttered)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Power points*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Electrical Cords*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Temperature / Humidity*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Lighting*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Easy exit*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Hygiene of furniture*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Smoke detectors are installed*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
KITCHEN-Are the following safe?
Work heights are suitable*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Seating available for meal preparation assistance*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Floor surface (level & smooth)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Electrical equipment and power points*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
LAUNDRY-Are the following safe?
Location of washing machine*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Floor surface (level & smooth)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Electrical cords*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Waste bin/basket for soiled items*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
BATHROOM-Are the following safe?
Access to shower, bath, toilet*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Floor surface (level & smooth)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Electrical equipment & cords*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Water temperature easy to control*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Ventilation*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
BEDROOM-Are the following safe?
Floor surface (level & smooth)*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Power points & electrical leads:*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Uncluttered*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Ventilation*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
MANUAL TASKS
Can you work without excessive bending, twisting or over-reaching?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Is the recipient, due to mobility issues, awkward to handle, unstable or unbalanced?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
Does the recipient utilise any equipment? (e.g.wheelchair, oxygen)*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
Is there a safe method for transferring the recipient up and down the stairs?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Is there a safe method to transfer the recipient in/out of the vehicle where required?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Is there equipment available to assist with the transferring of wheelchairs / wheelie walkers in/out of the car where required?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
Is there a safe method for assistance in showering/toileting etc?*

YesNoN/A
If 'no' then specify the nature of hazard identified and control measures implemented:
ANIMAL CARE
What animals live at the residence?*
Who generally feeds them?*
Are they inside pets?*
Animal toileting issues?*
Is there a plan for who looks after the animals if you go away?*
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?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
What are the normal smoking habits of the people who smoke? (where do they smoke, how are butts disposed of, how often do they smoke etc)*
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?*

YesNo
Recipient signature to acknowledge rights of LSW:*

Clear
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below*
DRINKING
Is there anyone in the household who drinks alcohol?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
When drinking, are there any concerns?*
Has it been explained to the consumer that the LSW has the right to end shift if the recipient is drinking/under the influence?*

YesNo
Recipient signature to acknowledge rights of LSW:*

Clear
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below*
DRUG TAKING
Is there anyone in the household who takes drugs?*

YesNoN/A
If 'yes' then specify the nature of hazard identified and control measures implemented:
What generally happens when this occurs?*
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?*

YesNo
Recipient signature to acknowledge rights of LSW:*

Clear
Recipient has agreed to the above and has offered verbal approval, rather than signature*

YesPhysical signature provided
If verbal consent provided, please state reason below*
OTHER ISSUES
Other issues not identified and /or comments: (recipient's residence unhealthy to work in eg.: rats/mice, food mess, clutter, personal hygiene, element of danger such as others who live with recipient, neighbours, behaviours appear unsafe etc)*
Were any risks identified during the WHS assessment?*

YesNo
PLEASE NOTIFY YOUR LINE MANAGER OF ANY RISKS IDENTIFIED
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)
selectability representative name*

First nameMiddle nameLast name
Signature*

Clear
Date

DayMonthYear
Date
selectability Representative Name*

First nameLast name
Signature*

Clear
Date

DayMonthYear
Date
Name of Team Leader notified*

First nameLast name
Date*

MonthDayYear
Date
Hazard identified in TRACCS*

YesNo
Date*

MonthDayYear
Date
Family / carer characteristics*

Low levels of attachment between family members (parent–child, sibling relationships)Past or current substance abusePerceived caregiver stressSocial isolationPower and control issuesPoor health and wellbeing, including social determinants such as low income, inadequate housing etc.Negative attitudes towards people with a disability demonstrated by family membersHigh levels of dependency (either on or by the person with a disability)Lack of awareness and use of formal supportsHistory of family violence and attitudes suggesting a tolerance of family violenceN/A
Strategies to reduce risk*
Individual characteristics*

Social isolation and lack of close relationshipsCommunication difficultiesChallenging or disruptive behaviourRisk taking and reckless behaviourHistory of drug and alcohol useCriminal history (Been to jail)Trouble with the police or courts (DVO, AVO?)History of inappropriate sexual behaviourHigh tolerance of violenceHistory of attempted suicide and/or self harmHistory of poor compliance with medications, treatment and servicesN/A
Strategies to reduce risk*
Protective factors*

Risk of harm to othersVulnerabilitiesLegal/restrictive practicesRisk of homelessnessN/A
Strategies to reduce risk*
Tick all that are completed:*

Provided Welcome PackCreated TRACCS recipient profileSaved intake form & supporting documentation to recipient's TRACCS profilecompleted WHS assessment and sent to selectability WHS delegate for sign offcompleted TRACCS notes for intakecompleted handover to appropriate Team Leader for implementation of services
Intake Meeting Attendees (please list)*
Notes:
Intake completed by:*

First nameMiddle nameLast name
Date

DayMonthYear
Date
Signature:*

Clear
FORM COMPLETION

Please press the submit button below to finish and submit this form.
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NDIS INDIVIDUAL INTAKE DOCUMENT

Recipient Information/Demographics and Preferences

Recipient Details

Nominee Details

Recipient Details Continued

Involved community supports/agencies

Referred Program - PROGRAM Recipients

Referred Program - NDIS Recipient

Consultation - PROGRAM Recipients

Consultation - NDIS Recipient

Agreement to Proceed - PROGRAM Recipients

Agreement to Proceed - NDIS Recipient

Support Worker Preferences

Shift Preferences - PROGRAMS

Shift Preferences - NDIS

Discussion of Recipient Rights

Release for Use of Images or Recordings

Recipient Needs, Interests, Achievements and Goals

Needs - (Communication & Disability)

Mobility and Personal Support Needs (Physical)

Needs - (Health)

K5

Emergency Disaster Assessment

Individual Care Plan - (Behaviours)

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

Confirmation

WHS Assessment

Work Health and Safety Assessment Checklist – Recipient’s Home

Important Questions

SMOKING

DRINKING

DRUG TAKING

selectability Employee acknowledgement

FORM COMPLETION