Adult Community Services Intake Form

  • Adult Community Services Intake Form

  • Welcome to Vital Care Australia Community Services

    Once we have received this completed form, our Adult Community Service team will contact you within 5 days to assess your support network, your main priorities and how we might be able to assist with your goals. We can then organise a time to visit one of our centres in Traralgon, VIC. If you any questions regarding this form, please call us on: 0450 745 626 or email: vitalcareaustralia@gmail.com

  • Participant Details - the person who will receive the supports
  • Date of Birth
     - -
  • Gender*
  • Format: (000) 000-0000.
  • How did you hear about VitalCare Australia ?*

  • NDIS Details

    VitalCare Australia is a registered NDIS provider.
  • Does the participant have an Autism diagnosis (by a health professional or self-diagnosis)?*
  • Does the participant have an NDIS plan ?*

  • Our centres in Melbourne offer a range of individualised programs and supports.

    They are open Monday to Friday from 9am to 3pm.
  • What types of skills are you looking to develop? (You can choose more that one)*
  • What activities are you interested in? (you can select more than one)*
  • Preference for the day(s) to attend our centre (you can select more than one)*

  • Enquirer Details

  • Who is completing this form? *
  • Format: (000) 000-0000.
  • Who is the best person to contact? *
  • Format: (000) 000-0000.
  • Is an interpreter required?*
  • Do they identify as Aboriginal or Torres Strait Islander?*
  • Who makes the decisions for this participant?*
  • Should be Empty: