Participant Intake / Assessment
Participant Details:
Full Name
*
First Name
Last Name
Preferred name
*
NDIS Number
*
Address
*
Street Address
Street Address Line 2
Suburb
State
Postcode
Phone Number
*
undefined
E-mail
*
example@example.com
Date of birth
*
-
Day
-
Month
Year
Date
Gender
*
Male
Female
Rather not say
Non-binary
Other
Do you identify as an Aboriginal or Torres Strait Islander?
*
Yes
No
Rather not say
Main language spoken
Living Arrangements
*
Lives alone
Lives with family
Lives with others
Lives in SIL
Are there any religious / cultural / spiritual matters that we need to be aware of?
*
Yes
No
If yes, please specify:
Primary Carer / Guardian Details
Secondary / Emergency Contact Details (leave blank if same as Primary Carer above)
Support Person Contact Details (leave blank if same as Primary Carer above)
What does {preferredName}'s Support Person usually help with?
Appointments
Planning
Invoices
General Support
Other
Is {preferredName} aware of this Support Person?
Yes
No
Unsure
How payments will be made
*
SELF MANAGED - Phoenix Community Project Inc will send the participant/participant's representative an invoice for the agreed supports for the participant/participant's representative to pay. The participant/participant's representative will pay the invoice by direct debit within 7 days.
NDIA MANAGED - After providing the agreed supports, Phoenix Community Project Inc will claim payment from the NDIA.
PLAN MANAGED - After providing the agreed supports, Phoenix Community Project Inc will claim payment from:
Plan Manager Provider Name
*
Plan Manager Email Address
*
example@example.com
Primary Disability
*
Secondary disability / Medical conditions
Please list
Is the use of other aides required (e.g. vision, hearing, mobility)?
*
Yes
No
If yes, please specify:
Medication
Is medication assistance required while at Phoenix?
*
Yes
No
Name of medication/s and what they are for:
Is the use of PRN (as needed) required while at Phoenix?
*
Yes
No
Name of medication/s and what they are for:
Have you attached a Primary Medication Chart with medication details? (there is an upload option at the end of this form)
*
Yes
No
N/A
Medical and Clinical information
General Practitioner's (GP) Details
Please list other Medical or Clinical Professionals that support you:
Asthma
Does {preferredName} have asthma?
*
Yes
No
If yes, has an Asthma Management Plan been provided? (there is an upload option at the end of this form)
Yes
No
Epilepsy
Does {preferredName} have epilepsy?
*
Yes
No
If yes, has an Epilepsy Management Plan been provided? (there is an upload option at the end of this form)
Yes
No
Diabetes
Does {preferredName} have diabetes?
*
Yes
No
If yes, has a Diabetes Management Plan been provided? (there is an upload option at the end of this form)
Yes
No
Allergies
Does {preferredName} have allergic reactions?
*
Yes
No
If yes, please list allergies:
If yes, has an Allergy Management Plan or Anaphylaxis Plan been provided? (there is an upload option at the end of this form)
Yes
No
Communication
How does {preferredName} communicate?
*
Verbal
Sign language
Gestures
Visual aids
Assistive communication device
Written communication
Are there any other communication needs? If yes, please specify:
Personal Supports and Safety
How does {preferredName} react to new carers?
*
Positive
Negative
Needs Encouragement
How does {preferredName} react to others?
*
Positive
Negative
Needs Encouragement
Further details if required:
Does {preferredName} have any fears?
*
Yes
No
If yes, please specify:
Does {preferredName} have road traffic awareness?
*
Yes
No
If no, please specify:
Is {preferredName} aware of danger?
*
Yes
No
If no, please specify:
Does {preferredName} have any risk-taking behaviours? (e.g. fire-lighting, illegal drug use, alcohol misuse, theft)
*
Yes
No
If yes, please specify:
Behaviours of Concern
Does {preferredName} exhibit any behaviours of concern? (please select all that apply)
*
Verbal aggression
Physical aggression
Self-injurious behaviour
Absconding
Sexualised behaviours
Has Restrictive Practice/s
Other
N/A
If yes, has a Behaviour Support Plan been provided? (there is an upload option at the end of this form)
Yes
No
Meals and Nutrition
Please list drinks and food that {preferredName} enjoys:
*
Please list drinks and food that {preferredName} dislikes:
*
Physical Activity and Sports
Please list sports and physical activities that {preferredName} enjoys:
*
Can {preferredName} swim?
*
Yes
No
How far can {preferredName} swim without physical assistance?
Enter in metres
Hobbies and Interests
What does {preferredName} enjoy doing?
*
What does {preferredName} NOT enjoy doing?
*
Personal Care
Can wash hands
*
Can shower / bath
*
Can wash, rinse own hair
*
Can dry self with towel
*
Can dress / undress self
*
Can comb / brush hair
*
Can clean own teeth
*
Can use toilet
*
Can wipe self
*
Can shave self
*
Can manage menstration
*
Continent
*
Legal Orders
Are there any legal orders involving {preferredName}?
*
Court Order
Family Law Order
Community Treatment Order
NCAT Guardianship Order
Other
N/A
Please provide detail:
Anything else we should know?
How did you find out about Phoenix?
*
Family / Friend
Support Coordinator
Other Provider
NDIS Service Directory
Social Media
Google
Other
Please upload a profile photo of {preferredName}
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of current NDIS Plan if you wish
Browse Files
Drag and drop files here
Choose a file
Please upload any current Plans, Reports or Assessments that you feel may help us provide our best level of support.
Cancel
of
Please upload any current Plans, Reports or Assessments that you feel may help us provide our best level of support.
Browse Files
Drag and drop files here
Choose a file
Please upload any current Plans, Reports or Assessments that you feel may help us provide our best level of support.
Cancel
of
Risk Assessment
Please read the overall risk category - if there are no risk applicable - select N/A for the section
Is {preferredName} subject to any of the following Significant Risk Factors?
High Intensity Personal Activities - please select all risks relevant to {preferredName}
Please provide details:
Hazard Exposure - please select all risks relevant to {preferredName}
Please provide details:
Environmental and Social - please select all risks relevant to {preferredName}
Please provide details:
Harm to Self or Others - please select all risks relevant to {preferredName}
Please provide details:
Relationships and Sexuality - please select all risks relevant to {preferredName}
Please provide details:
Unsafe Lifestyle Choices - please select all risks relevant to {preferredName}
Please provide details:
Abuse of Neglect - please select all risks relevant to {preferredName}
Please provide details:
Eating and Drinking - please select all risks relevant to {preferredName}
Please provide details:
Medical Conditions - please select all risks relevant to {preferredName}
Please provide details:
Medical intervention - please select all risks relevant to {preferredName}
Please provide details:
Mobility - please select all risks relevant to {preferredName}
Please provide details:
Personal Finance - please select all risks relevant to {preferredName}
Please provide details:
Name of person completing this form
*
First Name
Last Name
Signature
*
Submit
Submit
Should be Empty: