Post Intake Consultation Checklist (Staff Use Only)

Post Consultation Checklist

selectability staff member to please complete once intake meeting has occurred with consumer
Consumer Details
Region*
Full name:*

First NameLast Name
Preferred name:*
TRACCS record ID*
NDIS reference number (if applicable)
Date:

DayMonthYear
Date
Please specify below:*

Completed for NDIS-SD consumerCompleted for NDIS-SC consumerCompleted for NDIS-SIL consumerCompleted for Program consumerCompleted for Group Program consumer
If NDIS, please select membership discussed and agreed upon (if applicable):

Option 1 (5 hours per week)Option 2 (10 hours per week)Option 3 (15 hours per week)Option 4 (20 hours per week)
Third Party Input / Assistance To Complete

(Please only complete if applicable) If the consumer was unable to complete sections of the intake, please specify which sections and the reason why.
Tick if applicable*

Completed by third party (e.g. Family/Referrer/Guardian)No third party involved
Name of Third Party:*

First NameMiddle NameLast Name
Third Party's Relationship with Consumer:*
Completed (tick box)*

Communication and disabilityHealthFunctional needsSocial/emotional needsStar chartIndividual care planPreferencesInterests/achievements/strengthsGoals/individual support plan
Reason not completed by consumer:*
Risk Factor Assessment

This must be completed
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*
This list is not exhaustive and other factors may also contribute to or increase a person’s risk.
selectability delegate acknowledgement - (WHS)
I have reviewed this WHS assessment and informed the relevant Team Leader of any significant hazards identified that are requiring controls to mitigate the risks.
selectability Representative Name*

First nameLast name
Signature*

Clear
Date

DayMonthYear
Date
Name of Team Leader notified*

First nameLast name
Date*

DayMonthYear
Date
Hazard identified in TRACCS*

YesNo
Date*

DayMonthYear
Date
Post Intake Consultation Checklist
Tick all that are completed:*

Provided Welcome PackCreated TRACCS consumer profileSaved intake form & supporting documentation to individual'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
Next Review Date:

DayMonthYear
Date
Intake form sent to OPG for approval:*

YesN/A
FORM COMPLETION

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

Post Consultation Checklist

Consumer Details

Third Party Input / Assistance To Complete

Risk Factor Assessment

selectability delegate acknowledgement - (WHS)

Post Intake Consultation Checklist

FORM COMPLETION