NDIS GROUP PROGRAM INTAKE (RECIPIENTS)

NDIS GROUP PROGRAMS INTAKE DOCUMENT

This document is to be used in the initial interview with the recipient onboarding NDIS recipient into our Clubhouses, Mental Health Hubs.
Recipient information/Demographics and Preferences
Region*
Source of referral*
Please specify referral details below:*
Please specify the program/group you are accessing: *
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?*

NoYes
If yes, please state 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 consumer 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 you 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
Important Questions
At selectability, our purpose is to improve the mental wellbeing of people in regional Queensland and contribute to the prevention of suicide. These following questions allow us to gain an open and honest insight into your current mental wellbeing, to see how we can further support you in these areas.
Do you experience thoughts of suicide/self-harm?*

YesNo
Notes:
Do you have experiences of aggressive/outburst behaviours?*

YesNo
Notes:
Are you experiencing domestic violence or concerns around your safety?*

YesNo
Notes:
Consultation
Discuss in detail:

- The service delivery supports available through selectability (if NDIS, please refer to the NDIS Recipient Starting my Plan website page)

- Costs involved or how funding is accessed

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

- Other permissions
What is the main reason you are accessing this space/program? *
Have you been provided with a current Positive Behaviour Support Plan?*
If yes, does your Positive Behavious Support Plan have restrictive practices?

YesNoUnsure
If yes, may we have a copy?

YesNoN/A
Please specify restrictive practices below if applicable: *
Agreement to Proceed

Ask the recipient if they wish to proceed and engage with selectability, having received information about the services we can provide (including membership if NDIS)
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 selectability Welcome Pack)
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
If NDIS, please state below:*

NDIS consumerOther
NDIS Plan Start Date
NDIS Plan Expiry Date
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.*

Recipient agrees to provide their NDIS plan to selectabilityRecipient agrees to only provide the goals from their NDIS plan to selectabilityRecipient does not agree to provide plan or goals
Please confirm the below:*

Recipient agrees to signing an Individual Service AgreementRecipient does NOT agree (explain conditions of services)
Involved Community Supports/Agencies
Please provide names of the following providers along with their contact details:
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
Needs - (Communication, Disability & Health)
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 DisorderAutism (including Aspergers Syndrome and Pervasive Development Delay)Bipolar Affective DisorderBorderline Personality DisorderCerebral PalsyDementiaDissociative Identity DisorderDown SyndromeIntellectualNeurologicalObsessive-Compulsive DisorderPhysicalPsychiatricSchizophreniaSurgery/Medical ComplicationsOther
If physical or psychiatric diagnosis is identified, please specify:*
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:*
Details of any medical conditions/medical alert or allergies: (eg. epilepsy, asthma, diabetes, swallowing difficulties or dysphasia)*
Is a medical management plan required?*

YesNo
If yes, has this plan been provided/can we obtain a copy? (We cannot commence service until we have a copy of the medical management plan)

YesNo
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 medical 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
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, please specify:
Shift Preferences (if applicable)
Does your program require assigned workers for one-on-one support with recipients:*

YesNo - please continue with intake
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:*
Preferred Days of the Week:*

MondayTuesdayWednesdayThursdayFriday
Please specify start and finish times (please use 24-hr clock eg 0800 = 8am; 1700 = 5pm): *
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 tick the box below.
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
If, at any time, you change your mind about receiving marketing information from us you can email feedback@selectability.com.au or speak to a selectability employee.
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 (optional)

Clear
Legal representative name (optional)

First NameMiddle NameLast Name
Date

DayMonthYear
Date
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
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
Full Name*

First NameMiddle NameLast Name
Date*

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

Yes, verbal approval offeredNo, physical signature provided
Reason why verbal consent necessary
Does the recipient have a legal representative?

YesNo
Legal representative signature

Clear
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 Interests & Needs
Current engagement/helpful information:
What are your hobbies/interests?
Do you belong to or enjoy any clubs/groups/sporting activities?
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.

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 & 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
FORM COMPLETION

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

NDIS GROUP PROGRAMS INTAKE DOCUMENT

Recipient information/Demographics and Preferences

Recipient Details

Nominee Details

Recipient Details Continued

Important Questions

Consultation

Agreement to Proceed

Involved Community Supports/Agencies

Needs - (Communication, Disability & Health)

Shift Preferences (if applicable)

Discussion of Recipient Rights

Release for Use of Images or Recordings

Recipient Interests & Needs

K5

Emergency Disaster Assessment

Individual Care Plan - (Behaviours)

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

Confirmation

FORM COMPLETION