Assist Lifestyle Intake Form

Assist Lifestyle Intake Form

Understanding all this will help us provide the most suitable recommendations and tailored care.
Client Quick Intake Form
Name of Person making the Intake Form*

First NameLast Name
Relation to the NDIS Participant*
NDIS Participant Full Name*

First NameLast Name
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age of Participant*
Contact Phone Number*
Contact Email Address*
Preferred Communication*

Phone callTextEmail
Gender of Participant*

MaleFemaleGender DiversePrefer not to say
Capacity Building Support:*

Support Coordination Level 2Specialised Support Coordination Level 3Psychosocial Recovery CoachingAssistance with Accommodation and TenancyInnovative Community ParticipationDevelopment of Life Skills
Core Support*

In-Home Support (Daily Living Tasks)Household Tasks and CleaningAssistance with Travel and Transport (e.g. attending appointments, shopping)Community Access and Social Participation (e.g. art classes, cooking classes, interest groups, gardening)Therapy Dog (companion for Community Access - upon request)Supported Outdoor Activities (e.g. golf, archery, fishing, bushwalking, biking)Supported Getaways (Short Term Accommodation, Respite)Independent Living Options (ILO)
Primary Disability*

Physical disabilityPsychosocial or mental health conditionsIntellectual disabilityAutism spectrum disorderAcquired brain injuryVision impairmentDeaf or Hearing lossOther
Secondary Disability*
Does the participant have regular medication?*

YesNo
Use of Websterpack?*

YesNo
Is the participant able to self-medicate?*

YesNo
If the participant is not able to self-medicate, please provide medication plan below:*
Use of Medical Cannabis?*

YesNo
Is the participant fully verbal or non-verbal?*
Other consideration regarding communication*
Is the participant in need of mobility support?*

YesNo
If yes, please provide what type of mobility aid is needed below:*
Do you hold a disability parking permit?*

YesNo
Are there any support plans available to Assist Lifestyle to support Participant (please provide copy)

Behaviour SupportFCA OT ReportPsychology ReportOther
If there are any support plans available, please attach them here:

Cancelof
Types of behaviours displayed by the participant:

Self-harmChallenging behaviourAggressive behaviourUse of illicit drugs
If there are any legal orders, please specify: (Mental Health Order/ Domestic Violence Order/Public Trustee/ Public Guardian)
Do you have NDIS Funding?*

YesNo
Details of NDIS Funding?*

NDIS Plan ManagedNDIS Self ManagedNDIS Agency ManagedPrivately FundAge Care PackageOther
Any extra details about support services needed? (e.g. risks, specific requests, hours needed, preferred days and times, fortnightly/weekly/monthly services)*
Worker Preference*

MaleFemaleNo gender preference
Car preferences for Worker:*
Please verify that you are human*
If you’d like to provide more detailed information to help us tailor our services to your needs, please complete the Full Intake Form or the Domestic Assistance/Cleaning Intake Form for NDIS Cleaning Services attached below depending on your needed services and email it to support@assistlifestyle.com.au

To learn more about the services we offer, you’re welcome to download our PDF Brochure below.

For an overview of our processes, operational policies, and procedures, please refer to the Participant Information Booklet also attached below.
Assist Lifestyle Brochure
Participant Information Booklet
AL - Domestic Assistance/Cleaning Intake Form
Should be Empty:

Assist Lifestyle Intake Form

Client Quick Intake Form