NDIS Intake Form 2.0

Form Submission Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearForm Submission Date Read Only
NDIS Intake Form

For new or returning clients with the National Disability Insurance Scheme (NDIS).
1. Participant details
Participant first name
Participant last name
Preferred name
Pronouns
Gender
Another pronoun (please specify)
Another term (please specify)
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Territory

Post Code
Participant email (if applicable)
example@example.com
Participant phone number (if applicable)
For contact/nominee/service coordinator details, please enter in relevant section below, otherwise, leave blank.
2. Authorised representative
Does the participant have a guardian or plan nominee to act on their behalf?
Type
Nominee details

First NameLast Name
Relationship to participant
Nominee phone number
Nominee email
example@example.com
Guardian details

First NameLast Name
Guardian phone number
Guardian email
example@example.com
Other representative (please provide details)
Additional information/notes
Who is the best emergency contact?

Other (please provide details)
Who do we contact to schedule appointments with the participant?

Other (provide name, phone and email)
3. About the participant
Does the participant require an interpreter or specific support with communication?

Yes (Provide details)
Is the participant Aboriginal and/or Torres Strait Islander?
Are there any cultural/religious/spiritual considerations?
What are the participant’s current living arrangements?

Other (provide details)
Is the participant able to attend the office for appointments?
If we need to attend the participant’s residence, what safety considerations do our practitioners need to be aware of?
(e.g.: remote location, dogs on property, difficult to access, ID required)
4. Support details
Participant’s disability/diagnoses:
Therapy/Behaviour support requirements and details (behaviours of concern, previous BSP services utilised, etc.)
Behaviours of concern, previous BSP services utilised, etc.
What other reports/assessments have been completed? (please attach if available)
Reports/assessments

Attach any relevant documentation or reports.
Cancelof
Are there any restrictive practices in place?
Restrictive practice details
i.e. chemical restraint, mechanical restraint, physical restraint, environmental restraint or seclusion.
5. NDIS Funding & Support requirements
NDIS number
NDIS contact name (e.g., COS, LAC)
NDIS contact organisation
NDIS contact phone
NDIS contact email
example@example.com
Copy of NDIS plan (please upload if participant consents):

Please note: sharing your NDIS plan with us is entirely optional, but it does help us to understand your goals and support needs.
Cancelof
Funding type
(Please note: we cannot accept self-managed referrals)
Plan Manager details:
Does Participant have a Participant Record in PACE?
Healthstyles Clinic Organisation ID: 405 015 1727
Plan start date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearStarting date of the NDIS plan
Plan end date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearEnding date of the NDIS plan
Service Required/Funding available
Service required/funding available
Service required/funding available
Are funds listed in quarterly periods?
Additional funding information / notes
6. NDIS Goals
Participant's NDIS Goals
7. Consents
Please note: the information captured in this form is utilised to assess our capacity to provide services, and to commence the service provision process. Additional Consent details will be requested via our Service Agreement and Participant Information Consent form.
Should be Empty:

NDIS Intake Form

1. Participant details

2. Authorised representative

3. About the participant

4. Support details

5. NDIS Funding & Support requirements

6. NDIS Goals

7. Consents