Participant Intake Form
1. Participant Details
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
NDIS Number
*
Contact details
*
Email address
*
Language spoken at home:
*
Preferred option forcommunication
*
Email
Phone
Post
Residential Address:
*
Postal Address(if different fromabove)
*
Is there a Guardianship and/or Administration order in place?
*
Yes
No
Is there a Behaviour Management Plan in place?
*
Yes
No
Participants under the age of 18, under guardianship or in the care of family or caregivers, pleasecomplete below
Name of Parent/Guardian 1
Relationship toparticipant
*
Parent
Guardian
Caregiver
Other
Residential Address:
*
Postal Address(if different fromabove)
*
Contact details
*
Email address
*
Name ofParent/Guardian 2
*
Relationship toparticipant
*
Parent
Guardian
Caregiver
other
Residential Address:
*
Postal Address(if different from above)
*
Contact details
*
Email address
*
2.Disability / Medical Conditions including any diagnosis if relevant
*
*
*
Behaviour Support Plan documents collected for authorisation purposes
Yes
No
Behaviour Support Plan available on NDIS portal?
Yes
No
Other service providers currently using (include Specialist Behaviour Support Provider, ifrelevant)
Name
*
Address
*
Phonenumber/email
*
Frequency of use:
*
3. Health Care Information
Medicare Number
*
Write expiry date and Reference number
Private HealthcareProvider
*
Write Membership number and Reference number
Doctor Name
*
Address
*
Phone Number
*
4.Funding
NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)
*
Yes
NDIS Number:
*
NDIS Date:
*
*
Self Managed
Plan Managed
Please provide details for invoices
Name
*
Email
*
Comments
*
5.Preferences
Preferred name
*
ReligiousRequirements
*
Cultural Requirements
*
Communication device
*
Physical Assistance
*
Other Considerations
*
6. Goals and Aspirations
What do you want to achieve for yourself – life skills, physically, socially etc?
*
Immediately
*
In 6 months
*
Next year
*
7. Risk Assessment
Risk Assessment Tool
*
Strategies
Developed(YES)
Strategies
Developed(NO)
Identified in
Support Plan(YES)
Identified in
Support Plan(NO)
Individual risk profile
Safety Environment Checklist – Home
I understand that:
• This organisation owns these records.• Information within these records will be shared with other staff within the organisation onand 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.To the best of my knowledge, the information provided in this form is true and correct:
Participant Signature or
*
Parent / caregiver signature
*
Name of the person signing
*
Relationship to the participant, ifnot the participant
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: