• Referral and Participant Information

    Referral and Participant Information

    Participant Intake and Support Plan Information

  • This intake form is designed to help us understand your individual needs, preferences, and goals so we can provide high-quality, person-centred support through the NDIS. All information you provide will be treated with the utmost respect for your privacy and handled in strict confidence in accordance with relevant laws and organisational policies. Collecting this information is essential to ensure a smooth onboarding process and to enable us to deliver services that are tailored to your unique circumstances, promoting your well-being, independence, and choice throughout your support journey.

  • Section 1. General Participant Details

  • Format: 0000-000-000.
  • Participant Date of Birth
     - -
  • Is the Participant Aboriginal / Torres Strait Islander(ATSIC)?
  • Gender
  • Type of Residence

  • Section 2. Funding and Plan Management

  • Which funds are available?
  • NDIA Plan Start Date
     - -
  • NDIA Plan End Date
     - -
  • Are any supports being provided by another provider?
  • Does the Participant consent for us to collaborate with and share information with key stakeholders to assist in service provision?
  • Does the participant have an authorised Plan Nominee?

  • Contact details for the NDIA Plan Nominee (If applicable)

    A Plan Nominee is someone legally appointed to act on behalf of the participant.

  • Format: 0000-000-000.
  • Plan start Date
     - -
  • Does the participant have an Coordinator of Supports (COS)?

  • Contact details for the Coordinator of Supports.

     

  • Format: 0000-000-000.
  • Does the Participant have or wish to engage an Advocate or Support Person to speak, act and make decisions on their behalf?

  • A separate request form will be generated and must be completed.

  • Section 3. Participant Personal Details

  • Does the participant have a current Behavioural Support Plan?

  • If one has been provided, please ensure the details have been entered into ShiftCare.

  • Are there any known legal issues that may affect our delivery of service?
  • General Diagnosis. Please select all that apply
  • Format: 0000000000.

  • Section 4. Emergency Contact / Representative Details 1

  • Format: 0000000000.
  • Primary Contact Type
  • Advocate or Support Person Request Form Supplied?

  • Section 5. Emergency Contact / Representative Details 2

  • Format: 0000000000.
  • Secondary Contact Type
  • Advocate or Support Person Request Form Supplied

  • Section 6. Communication and Culture

  • What are your preferred communication styles or contact methods?
  • Communication Type
  • Is English the Primary Spoken Language?
  • Are you of a culturally or linguistically diverse background?
  • Is an interpreter required?
  • Do you have any specific culture, diversity, values and beliefs of which we should be aware or you would like to note.

  • Section 7. Participant Health and Dietary Information

  • Participant Physical Conditions Known or Disclosed
  • Participant Mental Health Conditions Known or Disclosed
  • Is Assistance with Medication Administration Required?

  • If assistance with medication is required, please complete the online Medication Consent Form and all forms required for managing the Administration of Medication.

  • Is there a history of hospital admissions?

  • Participant Dietary Requirements

  • Do You Have Specific Dietary Requirements?
  • Do You Have Any Known Allergies?

  • Section 8. Areas of Support Required

  • Functional Support Requirements. (tick all that apply)
  • Cognitive Health Support Requirements
  • Social Support Requirements
  • Mealtime Support Requirements

  • Section 9. Registration groups

    Must align with NDIA plan and billing codes
  • What Registration groups apply to the participant?

  •   
    0106 – Assistance in Coordinating or Managing Life Stages, Transitions and Supports
    Supports that assist participants to build capacity to coordinate their supports and navigate significant life transitions, such as moving home, changing schools or employment, or experiencing major life changes.
    This group commonly includes Support Coordination and Specialist Support Coordination, focused on strengthening decision‑making, service linkage, and plan implementation skills.

  • 0107 – Assistance with Daily Personal Activities
    Supports that assist a participant with personal daily activities where they are unable to complete these tasks independently due to disability.
    Examples include assistance with:

    Showering and personal hygiene
    Dressing and grooming
    Eating and drinking
    Toileting and continence support
    These supports are usually delivered one‑to‑one and may include supervision and prompting.

  • 0108 – Assistance with Travel / Transport Arrangements
    Supports that assist participants to access and use transport to participate in everyday activities.
    This includes help with:

    Planning and organising travel
    Using public transport
    Support during travel when required

    This group does not include the provision of transport funding itself, but rather assistance to use transport.

  • 0115 – Assistance with Daily Life Tasks in a Group or Shared Living Arrangement
    Supports that assist participants with daily life tasks when living in shared or group accommodation.
    These supports are delivered in a shared model, not individually priced, and include:

    Personal care and daily routines
    Shared household tasks
    Support to participate in communal living
    This registration group is commonly associated with SIL‑type living arrangements but applies specifically to group‑based daily living supports.

  • 0116 – Innovative Community Participation
    Supports that provide innovative or non‑traditional community‑based programs designed to develop social skills, independence, and community inclusion.
    These supports are typically:

    Not standard recreational activities
    Structured programs aimed at capacity building
    Delivered outside the participant’s home
    Examples include specialised community participation programs and skill‑building initiatives.

  • 0117 – Development of Daily Living and Life Skills
    Supports that assist participants to build skills for independence in daily and community life.
    This includes training and development in areas such as:

    Budgeting and money management
    Cooking and meal preparation
    Household management
    Social and communication skills
    The focus is capacity building, not ongoing task substitution

  • 0120 – Household Tasks
    Supports that assist a participant to manage and maintain their household when they are unable to do these tasks themselves.
    Examples include:

    Cleaning and tidying
    Laundry
    Meal preparation (basic)
    Yard maintenance (where reasonable and necessary)
    These supports are typically delivered individually and are not group‑based.

  • 0125 – Participation in Community, Social and Civic Activities
    Supports that assist participants to engage in community, social, recreational, or civic activities.
    This includes:

    Support to attend community events
    Assistance to participate in social groups or activities
    Support to build community connections
    The focus is on active participation, not therapy or skill training alone.

  • 0136 – Group and Centre‑Based Activities
    Supports delivered in a group or centre‑based environment that enable participants to participate in social, recreational, or skill‑based activities.
    These supports:

    Are usually delivered at a centre or structured group setting
    Support social inclusion and engagement
    Are not one‑to‑one supports
    Examples include day programs and structured group activities.

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  • Will the Participant be supported in the home? (must align with above registration groups)

  • Section 10. Participant Preferences and Goals

  • Are there any specific preferences when matching our staff to the participant?
  • Support Person Gender

  • Goals

  • CONSENT AND ACKNOWLEDGEMENT

  • By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.

  • I also consent to

  • Thankyou for completing this form and providing us with your information.

    Please click on the Green   Submit   button below and one of staff will get back to you as soon as possible.

  • Internal Use Only

  • The above participant will be assigned to the below staff member to determine suitability and if so, to complete the onboarding procedure.

  • Signed for and on behalf of Tessellate Support Services Limited ABN 67669984838:

  • Date
     - -

  • Staff note.

    When the below question is set to Yes and the Submit buton is selected, onboarding forms will be generated and alocated to the nominated staff member for completion with the client

  • Participant is suitable and ready for onboarding?
  • Should be Empty: