Participant Intake Form

2. Disability / Medical Details
Type any disability / medical conditions including any diagnosis if relevant:
Put item numbers per line.
Medication/s Required

Medication Assessment Tool

	Strategies Developed	Identified in Support Plan
Medication Plan and Consent Form
Medication - Self Medication Assessment
Medication Risk Identity Form

Behaviour Support
Behaviour Support Plan Documents Collected for Authorisation purposes (if relevant)

YesNo
Behaviour Support Plan available on NDIS portal?

YesNo
Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

3. Health Care Information
Medicare No.
Private Healthcare Provider

4. Funding
Select funding:

NDIS ManagedSelf ManagedPlan Managed
* For NDIS Managed - A copy of the NDIS plan MUST BE provided for NDIA managed participants.
Please provide details for invoices

5. Preferences

6. Goals and Aspirations
What do you want to achieve for yourself — life skills, physically, socially, etc?

7. Risk Assessment

Risk Assessment Tool

	Strategies Developed	Identified Support Plan
Individual Risk Assessment
Safety Environment Checklist - Home
Participant Safe Environment Risk Assessment
Nutrition and Swallowing Risk Checklist

I understand that:
- This organisation owns these records.
- Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
- I can ask to see records and receive a copy
- Records are archived for a set period according to policy and procedure
- I understand that all information obtained will be kept confidential
Participant's Signature

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Parent/Guardian/Caregiver's Signature

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Name of the person signing

First NameLast Name
Relationship to the participant (if you're not the participant)
Date

DayMonthYear
Date
Should be Empty: