Participant Intake Form

Participant Intake Form

Please complete all sections to help us understand your needs, preferences, and supports at The Studio Bendigo / Scribbles Allied Therapy / Catalyst Ability.
Participant Details
Participant’s First name
Participant Surname
Preferred Name
Date of Birth

DayMonthYear
Identifies as

Other
NDIS Number
Phone - Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Language spoken at home
Interpreter required
Preferred option for communication
Identifies as Aboriginal and Torres Strait Islander?
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is there a Guardianship and/or Administration order in place?
Is there a Behaviour Management Plan in place?
File Upload - Please attach a copy of Behaviour Support Plan

Cancelof
Parent or Guardian?
- Name of Parent/Guardian
- Primary Carer
- Lives with Participant
- Parent/Guardian Residential Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Parent/Guardian Phone - Home
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian Phone - Mobile
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian Email address
  example@example.com
- Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Relationship to participant
- Disability/Medical Conditions including diagnoses
- Additional Conditions/Disabilities
- Other Service Provider/s - Organisation Name
- Other Service Provider/s - Phone Number/Email
- Doctor’s Name
- Doctor’s Address
- Doctor’s Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Doctor’s Email Address
  example@example.com
- NDIS Plan Start Date
  
  DayMonthYear
  Date
- NDIS Plan End Date
  
  DayMonthYear
  Date
- Funding Management Type
- Invoice Contact Name
- Invoice Contact Email
  example@example.com
- Groups - Term 2 2026 - 9 Week Program
  
  Invoiced at $78.08 per hour x 2 hours per week - Please note, Groups are booked as a term length program and will be invoiced for the nine week period regardless of notification of non-attendance.
- Group Booking?
- Groups to be Booked
- Total Group Cost for Term
- Invoice from (select one)
- Billing Category
- Individual Services
- Core - Assistance with Daily Activities/Community Access
- Service Name
- Hourly Rate
- Frequency per week
- Hours Per Service/day
- Weekly Cost
- Annual Weekday Cost
- Annual Weekday Hours
- Please state days/times preferred for support
- Add A Weekend Or Public Holiday Support?
- Service Name
- Hourly Rate
- Frequency
- Hours Per Service/day
- Annual Cost
- Annual Saturday Hours
- Please state preferred times
- Add Another Weekend Support?
- Service Name
- Hourly Rate
- Frequency
- Hours Per Service/day
- Annual Cost
- Sunday Annual Hours
- Please state preferred times
- Public Holiday Support?
- Service Name
- Hourly Rate
- Frequency
- Hours Per Service/day
- Please state preferred times
- Annual Cost
- Annual PH Hours
- Weekly Kilometer Allowance
- Annual Kilometer Allowance
- Daily Activities or Community Access Summary
- Annual Daily Activity or Community Support
- Other Core Supports (Cleaning and Gardening)
- Cleaning Or Gardening
- Service Name
- Hourly Rate
- Frequency
- Hours Per Service
- Annual Cost
- Annual Gardening hours
- Type of Gardening Service Required
- Add Cleaning?
- Service Name
- Hourly Rate
- Frequency
- Hours Per Service
- Annual Cost
- Annual Cleaning Hours
- Type of Cleaning Service Required
- Core Annual Total
- Core Annual Total Funding Allocation
- Add Therapy Support (Social Work or Counselling Inc Art Therapy)
- Counselling (Inc Art Therapy)
- Hourly Rate
- Frequency
- Hours Per Service
- Annual Counselling/Art Therapy Cost
- Annual counselling hours
- Add Social Work?
- Social Work
- Hourly Rate
- Frequency
- Hours Per Service
- Annual Social Work Cost
- Social work annual hours
- Capacity Building Summary
- Annual Capacity Building Cost
- Other NDIS Item Name & Number (Please enter service/s you are after and we will contact you to discuss further)
- Religious Requirements?
- Additional information
- Cultural Requirements?
- Additional information
- Communication Aid/s?
- Additional information
- Physical Assistance Required?
- Additional information
- Dietary Requirements?
- Additional information
- Allergies?
- Additional information
- Other Considerations
- Personal Goals description
- Goals - Immediate
- Goals - 12 Months
- Groups Cost - One Term
- Core Total - Assistance with Daily Activities/Community Access/Gardening/Cleaning
- Capacity Building - Therapy Cost
- Total Annual Cost of Services Requested
- Participant’s Signature
- Authorised Representative’s Signature
- Name of the Person Signing
- Relationship to the Participant (if not the participant)
- Date of Signing
  
  DayMonthYear
  Date
Should be Empty:

Participant Intake Form

Participant Details

Groups - Term 2 2026 - 9 Week Program

Invoice from (select one)

Individual Services

Daily Activities or Community Access Summary

Other Core Supports (Cleaning and Gardening)

Core Annual Total

Capacity Building Summary