Bloom Healthcare Intake Form
Welcome to Bloom Healthcare!
We are excited to have been given the opportunity to work with you.
Prior to commencing with an initial appointment, we would like to get a clearer understanding of individual context so that we can ensure we are well prepared to deliver a tailored, safe and quality service.
Participant Name
*
First Name
Last Name
What is your relationship to the participant?
*
I am the Participant
Guardian
Support Coordinator
Treater
Family Member
Bloom Clinician
Other
Name
*
First Name
Last Name
Email
*
example@example.com
Contact Phone Number
*
State
*
Please Select
Australian Capital Territory (ACT)
New South Wales (NSW)
Northern Territory (NT)
Queensland (QLD)
South Australia (SA)
Tasmania (TAS)
Victoria (VIC)
Western Australia (WA)
Intake Questions
Help us understand a little more about the referral.
Does the Participant require additional support to make decisions?
*
Yes
No
Are there additional people in the Participants Support Team (informal supports) who assist them in making decisions that you would like us to be made aware of?
*
Does the Participant have a nominee or is there a Guardianship in place? E.g., Child protection, adult guardianship.
*
Yes
No
Unsure
Name
*
First Name
Last Name
Email
*
example@example.com
Contact Phone Number
*
What is the Participants current Diagnosis, please detail...
*
Select the accepted disability type
*
Please Select
ABI
Autism
Cerebral Palsy
Down Syndrome
Global Developmental Delay
Hearing Impairment
Intellectual Disability
Multiple Sclerosis
Other Neurological
Other Physical
Other Sensory Speech
Psychosocial Disability
Spinal Cord Injury
Stroke
Visual Impairment
Other
Other
*
Are there any previous relevant reports? Are you able to share these with the clinician allocated to work with the Participant?
*
Yes
No
Unsure
Please upload previous relevant reports you are able to share
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How many hours would you like to allocate to our services?
*
Rows
Allocated Hours
Psychology
Occupational Therapy
Speech Pathology
Physiotherapy / Exercise Physiology
Positive Behaviour Support (PBS)
Dietetics
What service would you like provided? (if not already provided)
*
Intervention sessions
Functional assessment and report writing
Assistive Technology Assessment
Home and Living Assessment
Other
Presenting concerns/reason for referral (outside of what may have been already discussed)?
*
Who will be signing the Service Agreement?
*
Participant
Guardian/Parent
OPG
Other
Name of person signing the Service Agreement?
*
First Name
Last Name
Are other languages other than English spoken in the home?
*
Yes
No
Unsure
Please select ALL the languages spoken
*
Albanian
Amharic
Arabic
Armenian
Assyrian
Auslan
Bangla (Bengali)
Bosnian
Bulgarian
Burmese
Cantonese
Croatian
Dari
Dinka
Dutch
English
Farsi
Filipino
Finnish
French
German
Greek
Gujarati
Hakha Chin
Hazaragi
Hebrew
Hindi
Hmong
Indonesian
Italian
Japanese
Karen
Khmer
Kirundi
Korean
Kurdish Kurmanji
Lao
Macedonian
Malayalam
Maltese
Mandarin
Nepali
Pashto
Polish
Portuguese
Punjabi
Rohingya
Romanian
Samoan
Serbian
Sinhalese
Slovak, Slovenian
Somali
Spanish
Swahili
Tagalog
Tamil
Thai
Tibetan
Tigrinya
Turkish
Urdu
Vietnamese
Other
Please provide details of the other languages spoken...
*
Is an interpreter required to be arranged by Bloom Healthcare?
*
Yes
No
Unsure
What is the PRIMARY language for the interpreter?
*
What is the Participants / Guardian / Nominee's preferred communication method?
*
Phone
Email
SMS/Text
No preference
Who should the assessment and/or intervention appointments be conducted with or who is best to contact to organise the initial appointment? E.g., The Participant along with a support worker and translator or parent/guardian?
*
Does the Participant take any medications?
*
Yes
No
Unsure
Please detail all medications
*
Does the Participant present with any medical risk? (i.e. risk associated with medical conditions)
*
Yes
No
Unsure
FLAG
Please detail the risks...
*
Are there any variables that limit the Participant’s capacity to communicate with the clinician?
*
Yes
No
Unsure
Please provide details...
*
Is the Participant of Aboriginal or Torres Strait islander background?
*
Yes
No
Are there any cultural considerations we should be making as part of our service?
*
Yes
No
Unsure
FLAG
What are the considerations...
*
Do visitors, residents or neighbors present any risk to clinicians or the Participant?
*
Yes
No
Unsure
N/A (Clinic or Community visit)
FLAG
What risks to they present...
*
Does the Participant currently have, or have they recently been diagnosed with, any infectious diseases?
*
Yes
No
Unsure
FLAG
Please provide details...
*
Does the participant or anyone in the home have a current or past history of substance abuse?
*
Yes
No
Unsure
FLAG
Please provide details...
*
Are there weapons in the home?
*
Yes
No
Unsure
N/A (Clinic or Community visit)
FLAG
What weapons are in the home - please provide a complete list...
*
Are there pets in the home?
*
Yes
No
Unsure
N/A (Clinic or Community visit)
Please detail what pets are in the home...
*
Are the pets generally friendly and approachable?
*
Yes
NO
FLAG
Have there been any incidents of aggression or bites from the pets in the past?
*
Yes
No
FLAG
Are there specific areas of the home where the pets are able to be kept/secured during service visits?
*
Yes
No
Does anyone in the home hoard or is there damaged property within the residence?
*
Yes
No
Unsure
N/A (Clinic or Community visit)
FLAG
Please provide details...
*
Does the Participant have a history of aggression?
*
Yes
No
Unsure
FLAG
Please provide details...
*
Does the participant or anyone in the home have a history of criminal offences?
*
Yes
No
Unsure
FLAG
Please details criminal offences...
*
Have clinical files been subpoenaed for this Participant in the past?
*
Yes
No
Unsure
FLAG
What files have been subpoenaed?
*
Is there any pending legal (civil or criminal) matters or anticipated need for clinical files to be subpoenaed?
*
Yes
No
Does the Participant present with any behaviours of concern (i.e., biting, hitting, kicking, throwing, hair pulling, destruction of property?
*
Yes
No
Unsure
FLAG
Please provide details...
*
Are the behaviours of concern specific to certain situations or triggers?
*
Yes
No
Please provide details...
*
Have interventions or strategies been implemented to address or manage these behaviours?
*
Yes
No
Is there a history of these behaviours resulting in harm to the participant or others?
*
Yes
No
Are there any triggers that we should be aware of prior to engagement with the Participant?
*
Yes
No
Unsure
FLAG
Please detail all triggers...
*
Are there any restrictive or safeguarding practises utilised within the environment Bloom Healthcare should be aware of? (i.e., front door being locked with keys caregiver keeps on their person)
*
Yes
No
Unsure
FLAG
Please detail....
Is there difficulty with mobile reception at the requested location?
*
Yes
No
Unsure
FLAG
As we are a mobile service, our clinical contact is made largely in the home. If you have any reason to believe that a home visit may present a risk to the Participant or clinician, please record that below and we will review to present a suitable alternative location.
*
Yes
No
Please detail...
*
FLAG
Risk Rating
Submit
Should be Empty: