Participant Intake Form

Your Life Your Choice Care Services Participant Intake Form
Participant's Name*
Date of Birth*

DayMonthYear
Date
What kind of support does the participant need? (Select all that apply)*

Support CoordinationFinding accommodation or housingGetting daily personal or household helpTransport or getting out in the communityBuilding independence and life skillsNot sure yet. Please contact us
Gender*

FemaleMaleNon-binaryOther
NDIS Number*
Phone*
Email*
Language Spoken at Home*
Interpreter Required?*

YesNo
Preferred Language*
Identifies as Aboriginal and Torres Strait Islander?*

YesNo
Prefered Option for Communication*

EmailPhonePost
Residential Address
Postal Address

Same as residential address
Postal Address

Guardianship and/or Administration Order and Behaviour Management Plan*

	Yes or No
Is there a Guardianship and/or Administration order in place?
Is there a Behaviour Management Plan in place?

Provide the following information for participants under the age of 18, under guardianship or in the care of family or caregivers.
Name of Parent/Caregiver/Guardian
Relationship to Participant

ParentGuardianCaregiverOther
Primary Carer?
Lives with Participant?
Emergency Contact?
Parent/Caregiver/Guardian Residential Address
Parent/Caregiver/Guardian Postal Address

Same as residential address
Parent/Caregiver/Guardian Postal Address
Parent/Caregiver/Guardian Phone
Parent/Caregiver/Guardian Email
Add Another Guardian?

YesNo
Name of Parent/Caregiver/Guardian
Relationship to Participant

ParentGuardianCaregiverOther
Primary Carer?
Lives with Participant?
Emergency Contact?
Parent/Caregiver/Guardian Residential Address
Parent/Caregiver/Guardian Postal Address

Same as residential address
Parent/Caregiver/Guardian Postal Address
Parent/Caregiver/Guardian Phone
Parent/Caregiver/Guardian Email
Participant's Disability / Medical Conditions, including diagnoses

Medication/s Required - Strategies Developed*

	Strategies Developed
Medication Plan and Consent Form
Medication – Self Medication Assessment
Medication Risk Indemnity Form

Medication/s Required - Identified in Support Plan*

	Identified in Support Plan
Medication Plan and Consent Form
Medication – Self Medication Assessment
Medication Risk Indemnity Form

Behaviour Support*

	Yes or No
Behaviour Support Plan documents collected for authorisation purposes
Behaviour Support Plan available on NDIS portal?

Other Service Providers

Include Specialist Behaviour Support Provider, if relevant
Health Care Information
Medicare Number*
Expiry Date*
Reference Number*
Private Healthcare Provider
Membership Number
Reference Number
Doctor's Name
Doctor's Address
Doctor's Phone Number
Doctor's Email
Funding
How is your plan managed?*
A copy of the NDIS plan must be provided for NDIA-Managed participants.
Upload NDIS Plan (if available)

Cancelof
Plan Start Date*

DayMonthYear
Plan End Date*

DayMonthYear
Provide Details for Invoices
Personal Preferences
Personal Goals
Describe your personal goals – life skills, physically, socially?*
Short-Term Goals (0–6 months): What would you like to achieve soon?*
Long-Term Goals (6–12+ months): What would you like to achieve in the future?*

Risk Assessment - Strategies Developed*

	Strategies Developed
Individual Risk Assessment Profile
Safety Environment Checklist – Home
Participant Safe Environment Risk Assessment
Nutrition and Swallowing Risk Checklist

Risk Assessment - Identified in Support Plan*

	Identified in Support Plan
Individual Risk Assessment Profile
Safety Environment Checklist – Home
Participant Safe Environment Risk Assessment
Nutrition and Swallowing Risk Checklist

Who is signing this form?*

ParticipantAuthorised Representative/Parent
Note: Authority to Act as an Advocate form is required if the individual signing this form is not the participant.
Participant Acknowledgement

I understand that:
- Your Life Your Choice Care Services owns these records.
- Information within these records will be shared with other relevant workers within the
  organisation only when the relevant worker requires the information to carry out their
  duties and provide safe and quality services and support.
- I can ask to see my personal records at any time, and receive a copy for my records.
- My personal records are archived for a set period according to legislative and
  organisational policy requirements.
- I understand that all information obtained will be kept secure, private and confidential.
To the best of my knowledge, the information provided in this form is true and correct:
Participant’s Signature*

Clear
Authorised Representative’s/Parent’s Signature (if applicable)*

Clear
Name of the Person Signing*
Relationship to the Participant*
Date*

DayMonthYear
Date
Should be Empty:

Your Life Your Choice Care Services Participant Intake Form