Client Intake Form

Date

Region*

Service*

Participant Name*

First NameLast Name

Date of Birth*

Date

Current Age

Gender*

Phone Number

Please enter a valid phone number.

Email

example@example.com

Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Language spoken at home*

Interpreter required?*

YesNo

Preferences for communication

EmailSMSPhonePost

Is there Guardianship and/or Administration order in place*

YesNo

Name of Parent/Guardian 1

First NameLast Name

Relationship to Participant

ParentGuardianCaregiverOther

Details

	Yes	No
Primary Carer
Lives with Participant
Emergency Contact

Parent/Guardian 1 Mobile

Parent/Guardian 1 Email

example@example.com

Parent/Guarding 1 Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Parent/Guardian 2

First NameLast Name

Relationship to Participant

ParentGuardianCaregiverOther

Details

	Yes	No
Primary Carer
Lives with Participant
Emergency Contact

Parent/Guardian 2 Mobile

Parent/Guardian 2 Email

example@example.com

Parent/Guarding 2 Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Disabilities*

Physical disabilityIntellectual disabilityDevelopmental disordersMental health disorders

Physical disabilities

Intellectual Disability

Developmental Disorders

Mental Health Disorders

Depression and Anxiety DisordersBipolar Disorder and SchizophreniaPost-Traumatic Stress Disorder (PTSD)Other

Other disability information

Disability / Medical information file upload

Please complete every row; this helps us to identify participant safety requirements.

Disability-related Health Supports (High-Intensity)*

	Yes	No
Dysphagia: for participants who have trouble eating, drinking or swallowing on a daily basis.
Respiratory: for participants requiring help with their breathing and maintenance of their respiratory health, including any associated care, comfort, planning or supports - including ventilator management.
Nutrition: for participants requiring help with the way they eat or understanding the food they need.
Diabetes: for participants who have daily problems with how much sugar is in their blood.
Complex Bowel Care: for participants who need daily assistance with continence i.e. toileting (bladder and bowel).
Complex Wound Management & Pressure Care: for participants who need daily wound and pressure care (resulting from pressure wounds or swollen limbs).
Podiatry: for participants who require help looking after their feet, ankles and lower limbs.
Epilepsy: for participants who need daily help managing the way epilepsy affects the way their brain and nerves work.
Botox and Splinting: It is unlikely Botox and splinting supports will be reasonable and necessary to include, as these are generally provided in a clinical setting.
Tracheostomy management.
Urinary Catheter Management (In-dwelling Urinary Catheter, In-out Catheter, Suprapubic Catheter).
Subcutaneous Injections.
Enteral (Naso-Gastric Tube - Jejunum or Duodenum) Feeding and Management.

Allergies

Food allergies

	Yes	Treatment	Response/comments
Peanuts and tree nuts
Shellfish and fish
Milk (typically in children)
Eggs
Wheat
Soy

Insect allergies

	Yes	Treatment	Response/comments
Bees
Wasps
Mosquitoes
Ticks

Airborne allergies

	Yes	Treatment	Response/comments
Pollen (from trees, grass, weeds)
Mold spores
Dust mites
Pet dander (from cats, dogs, birds, etc.)

Drug allergies

	Yes	Treatment	Response/comments
Penicillin and related antibiotics
Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs)
Antiseizure drugs
Chemotherapy drugs

Contact allergies

	Yes	Treatment	Response/comments
Latex
Nickel (found in jewelry and some cell phones)
Certain fragrances and cosmetics
Poison ivy, poison oak, and poison sumac
Certain topical medications

Other allergies

	Yes	Treatment	Response/comments
Allergy to sunlight (Solar Urticaria)
Allergy to cold (Cold Urticaria)

Other services currently supporting

	Name	Address	Phone	Email	Days of service
1
2
3

Health Care Information

	Number	Expiry Date:	Reference Number
Medicare
Private Healthcare

Approved contacts

	Name	Practice Name	Phone	Email	Location
Emergency contact
Doctor
Pharmacist
Pediatrician
Psychologist
Behaviour Support Practitioner
Physio
Occupational Therapist
Support Coordinator

Preferences

	Details
Preferred name
Religious requirements
Cultural requirements
Communication device
Physical assistance
Other considerations

What do you want to achieve for yourself - life skills, physically, socially etc.

	Details
Immediately
In 6 months
In 12 months

As part of the service we would appreciate assistance with the following for the participant*

Assistance with improved self care/independence/emotional regulationAssistance with relationship building/social skillsAssistance with mental health/emotional safetyAssistance with preparation for the workforceAssistance for preparation for household managementAssistance with building self esteem and self knowledgeAssistance in accessing relevant community activities in line with interestsDevelopment of a Care Plan and Specific ActivitiesDevelopment of an Emergency and Disaster Management strategy for your participant while in our care

Please note that Alorah Care will provide a care plan for the participant which can be requested at any time.

Emergency and disaster provisions will be made for participants' support.

Services*

Access Community Social and Rec Activ (Community Access)Assistance With Self-Care Activities (In-Home Care)

Supports Required*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hours

Select how services will be paid*

Self Managed (Invoice to Participant/Guardian)Plan Managed (Invoice to plan managers)

Plan Manager

Plan Manager phone

Please enter a valid phone number.

Plan Manager email

example@example.com

NDIS Plan Upload*

Authorised signer

Authorised person name

First NameLast Name

Authorised person email

example@example.com

Participant or Participant's representative signature

Alorah Care Email

jonathan@alorahcare.com.au

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Document#1 - V.4/03/2024

Client Intake Form

Participant Details

Parent/ Guardian details

Disability / Medical Conditions including any diagnosis if relevant

Goals and aspirations

Supports

Funding

NDIS Plan