V3 (NEW) Intake Form

  • Welcome to Paylos!

    We’re glad you’re here! 😊 This form is the first step in getting to know you (or your participant) so we can provide the right support. The more we understand, the better we can tailor our programs and create a positive, meaningful experience. 

  • Personal Information

    Let’s start with the basics. All information is kept safe and confidential within Paylos, and is only used to support service and care planning.
  • Format: 0000-000-000.
  • Relationship to Participant*
  • Consent for Referral*
  • Type of Funding*
  • How Did You Find Out About Paylos?*
  • Which Paylos offering are you interested in?*
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  • Participant Details

  • Gender Identity*
  • Date of Birth*
     - -
  • Does the participant have a Companion Card?
  • Is the participant of Aboriginal and/or Torres Strait Islander Support Networks descent?*

  • Participant Aboriginal and/or Torres Strait Islander Support Networks

  • Format: 0000-000-000.
  • Format: 0000-000-000.
  • Does the participant require a Cultural plan?
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  • Legal Guardian Details

  • Format: 0000-000-000.
  • Preferred Contact Method*

  • Brief Assessment of the Participant

  • Participant Health/Medical Details:

  • Does the participant require medication management?
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  • Medical Conditions

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  • Doctor's Details

  • Does Paylos have Consent to contact GP?*
  • Format: 0000-000-000.

  • Assistance with Self Care and Daily Support 

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  • Behaviours of Concern

  • Does the participant currently have any risks/behaviours?
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  • Support Requirement & Capacity

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  • In Case of Emergency

  • Does the participant have the capacity to understand what to do in an Emergency?*
  • Does the participant know how to call 000 and respond correctly?*

  • Existing Support

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  • NDIS Plan Details

  • Start Plan Date*
     - -
  • End Plan Date *
     - -
  • How is your NDIS Plan Managed?*
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  • Medication Consent

  • Does Paylos Staff have consent to support the participant administering medication whilst on shift?*

  • If there is a chance of Paylos staff administering medications within shift hours, please provide a completed treatment sheet filled out by the client’s GP with all current medications listed. It is your responsibility to ensure Paylos is notified and provided with an up-to-date treatment sheet if medications or administration times change prior to staff’s involvement within administration.

    If medication has been prescribed due to a diagnosed condition, Paylos will need a written diagnosis by a medication practitioner.

     

    POLICY: Please note ALL medication must be provided in a Pharmacist packed dosette (i.e.Webster Pack) or original packaging. A Medication Administration Form (Treatment Sheet) must be signed by a Treating Medical Professional prior to medication being administered at Paylos.

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