• Caura Client Intake Form

  • Intake Information

  • Start DateTime*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Referral

  • Format: 0000000000.
  • Referral Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • Core Client Information

  • Which program are you enrolling in?*

  • Identity

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Sex, gender and pronouns

  • Contact information

  • Format: 0000000000.
  • Format: 0000000000.
  • How would you prefer to be contacted?

  • Residential address

  • Postal address

  • Is your postal address the same as your residential address?*

  • Emergency contact

  • Format: 0000000000.
  • Format: 0000000000.

  • Representative or advocate

  • Do you have a representative or advocate?*
  • Format: 0000000000.
  • Does your representative live with you?

  • Demographic information

  • Do you need an interpreter?*

  • Consents

  • Do you consent to Caura collecting and using your personal information under our privacy policy?*
  • Do you consent to photographic identification being kept on your file, and used for support provision only?*

  • NDIS plan and funding

  • We use this information to understand the supports Caura may provide. It does not by itself confirm that Caura will deliver a service.

  • Plan details

  • Plan Start Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Plan End Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Is a current NDIS plan available to Caura?*
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  • How is the fund managed?*

  • IMPORTANT

    You must contact the NDIA to endorse Caura.

    Provider ID: 4050059061

  • Plan Funding

  • Enter a budget in dollars for each funded category (for example 1250.50). Leave blank when not funded.

     

  • Core
    Rows
  • Recurring
    Rows
  • Capital
    Rows
  • Capacity building
    Rows
  • The budget figures above are in which format?

  • IMPORTANT! - Please do not mix funding periods, all figures should be in the same unit type.

  • Support coordinator

  • Does the participant have a Support Coordinator?*

  • Guardian

  • Will a guardian, nominee or representative make decisions or sign documents?*
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  • NDIS Services

  • Required Services

  • Other Requirements

  • Will Caura provide Supported Independent Living?*
  • Will Caura provide Specialist Disability Accommodation?*
  • Will Caura implement the Behaviour Support Plan?*

  • Rights and privacy

  • 1. Rights, complaints, and advocacy

    You have the same rights as everyone else. Caura must treat you with courtesy and respect, keep you safe, and involve you in decisions about your supports.

    You have choice and control. You help decide what supports you get, when, how, and who provides them.

    You can have a family member, friend, or independent advocate with you at assessments, meetings, and whenever we talk about your supports.

    An advocate is someone on your side who can speak with you or for you. They are not Caura staff. You choose them, and you can change or withdraw that choice at any time.

    If you want an advocate and do not have one, we can help you find one, including through the Disability Advocacy Finder:  disabilityadvocacyfinder.dss.gov.au.

    We welcome feedback, compliments, and complaints. You do not have to say the word “complaint”. If something is not right, we treat it seriously.

    You will not be treated worse because you raise a concern.

    You can complain to Caura by:

    • telling any worker (we can write it down for you)
    • contacting the Complaints Manager
    • using a complaints form, including anonymously
    • email, phone, or post

    You can complain to the NDIS Quality and Safeguards Commission at any time, even if you have not complained to us first:

    • Phone 1800 035 544 (free from a landline)
    • TTY 133 677 (interpreters can be arranged)

    National Relay Service, then ask for 1800 035 544 We will listen, keep the matter private, keep you (and your advocate) updated, explain our decision, and tell you how to have it reviewed.

    We can offer Easy Read, an interpreter, or help to write the complaint.

    If they ask “what happens next?”

    We record it, look into it fairly, and work with you on a fix.

    If the complaint is about the CEO or senior management, you can go straight to the Commission.

    Staff — confirm current Caura contacts before the visit. 

    NDIS documents still name a Complaints Manager and mobile. Give the current name, phone, email, and postal address from the welcome pack or coordinator, not an outdated line.

     

  • Have we explained your rights as an NDIS participant, how to raise a concern or make a complaint to Caura or externally, and how to get independent advocacy support?*

  • 2. How we handle personal information

    We collect only what we need to plan, deliver, and review your NDIS supports — for example your name and contact details, NDIS number and plan information, health and support needs, goals, risks, and who is in your support network.

    We collect it from you (and from people you agree we can talk to) on this intake form, assessments, and your support plan.

    We use it to:

    • understand your needs and keep you safe
    • roster the right workers
    • coordinate with people involved in your supports
    • keep required records and meet NDIS and privacy law

    We store it in your participant file — electronic systems and, if needed, locked paper files. Only staff involved in your supports should see it.

    We do not share your information with other people or organisations unless:

    • you (or your guardian) agree, or
    • the law requires us to (for example some safety or Commission reporting)

    People it may be shared with, if needed for your agreed supports, include:

    • your support workers and coordinators at Caura
    • your nominated advocate, family member, or representative
    • other providers or clinicians involved in your supports
    • your Support Coordinator or Plan Manager, if you have one
    • the NDIA / NDIS Commission when required

    Photos, videos, or website/social media use are not part of this. That is a separate optional consent.

    You can ask to see your information, and ask us to correct anything that is wrong. Ask your coordinator or the office — we will help you do that.

    You can ask us to explain this again in Easy Read, another language, or with an interpreter.

    You can raise a privacy concern the same way as any other complaint, including to the NDIS Commission.

  • Have we explained how Caura collects, uses, stores and shares your personal information, who it may be shared with for your supports, and how you can ask to access or correct it?*

  • 3. Consent to collect, store, and share for supports

    This question is asking: is it okay for Caura to collect, keep, and share your information with the people who need it to deliver the supports we have agreed?

    Examples: your support worker knowing your address and how you like support done; a clinician or Support Coordinator if they are part of your team; billing or plan-management details so we can claim correctly.

    We will not share more than is needed. We will not share with people who are not involved in your supports.

    You can say who may see your records (for example Support Coordinator, Plan Manager, family, school, other practitioners). We record that.

    You can change your mind later. Tell us, and we will update who we share with.

    There are two limits:

    • we may still need to share if the law requires it (for example to keep someone safe)
    • if you do not consent to information we must have to deliver a support, we may not be able to provide that support until we work out another way

    If you are under 18, a parent, guardian, or authorised representative usually gives this consent.

    NDIS audit access to your file is optional. You can opt out. That is a later question, not this one.

    Photos and publishing quotes are not included here.

  • Do you consent to Caura collecting, storing and sharing your personal information with people and organisations involved in delivering your agreed supports?*
  • Is a third-party information release needed?*

  • Optional consents

  • Consent to telehealth where it is used
  • Is money or property support agreed?
  • Consent to publish photos or videos of the participant
  • Where may photos or videos be published?
  • Consent to publish feedback or quotes
  • Consent to participate in NDIS audit activities if requested

  • Decision-making and communication

  • Support Plan

  • Key Services & Contacts
  • Support Levels*
    Rows

  • Health, safety and behaviour support

  • Does the participant use medication?*

  • Behaviour support

  • Is there a Behaviour Support Plan in place?*
  • Is a regulated restrictive practice used or proposed?*
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  • Risk ratings

  • Living arrangement

  • Medication Information & Consents

  • Record how medication is managed. If Caura assists, complete the medication risk assessment. If the participant self-administers, complete the risk indemnity.

  • Are controlled medicines used by the client?*
  • Consent for Caura to assist with medication*
  • Medication hazard controls*
    Rows

  • Risk warning and exclusion of legal liability - Remove this - Should go to Client or Rep

  • This acknowledgement is for participants who self-administer medication that may carry risk. Caura’s duty of care is to inform the participant of those risks. Self-administration is undertaken at the participant’s own risk.

    The participant (or advocate) acknowledges that they choose to undertake medication administration that may carry risks, including adverse reactions that may result in health issues, permanent disability, or death; that they have been advised of potential risks; and that self-administration is entirely at their own risk.

  • Nutrition and swallowing risk assessment

  • Assess at commencement, annual, or if a decline in nutrition or swallowing is observed. Participant identity is taken from the core intake answers.

  • Nutrition issue checklist

  • Does the person…*
    Rows

  • Swallowing issue checklist

  • Does the person…*
    Rows

  • Third-party information release

  • Complete this consent when personal information may be released to a named organisation. Participant identity is taken from the core intake answers.

  • Format: 0000000000.
  • Information that caura is permitted to release to third party?*
  • I consent to Caura releasing the information described above to this organisation*
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  • Authority to act as an advocate

  • The participant authorises the named representative to act as their advocate with Caura. Participant and representative identity is taken from earlier answers where available.

  • Medical emergency plan

  • Document the response plan for potential medical emergencies. The primary emergency contact from core intake is already on file. Add GP details or an additional emergency contact only if needed.

  • GP

  • Format: 0000000000.
  • Format: 0000000000.

  • Emergency response plan

  • High-intensity daily personal activities

  • Select each activity Caura is contracted to provide. Staff must link current instructions and worker competency before delivery.

  • Activities

  • High-intensity activities Caura will provide*

  • Clinical protocol

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  • Protocol review date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Behaviour Support Plan implementation

  • Record Caura's role in implementing the current plan. A restrictive practice requires separate authorisation and reporting controls.

  • Provider and role

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  • BSP review date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Specialised Support Coordination

  • Capture the complexity, crisis prevention and participant-authorised network information needed for the specialised coordination role.

  • Complexity

  • Consent and disclosure

  • Participant consents to coordination with their support network and mainstream services*

  • Specialist Disability Accommodation

  • Complete only when Caura is the SDA provider. SDA housing arrangements remain separate from SIL support arrangements.

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  • SDA service and tenancy terms explained to participant*

  • Supported Independent Living

  • Complete only when Caura is contracted to deliver SIL. Housing, tenancy and support must be clearly separated.

  • At home

  • Continuity

  • Housing and support arrangements are separately explained and documented*

  • Supported Employment

  • Supported Employment is delivered under the Core module. It is not Module 6 Verification.

  • Goals and workplace

  • Supports and risk

  • CHSP Intake

  • Enter the client's My Aged Care number (MAC ID). Referral services selected here inform care planning and ShiftCare routing for domestic assistance and home maintenance.

    Format: AC followed by 8 digits (e.g. AC12345678). Digits-only input is auto-formatted.

  • MAC Referral Services
  • Do Our Staff Have Consent to Enter Property if Client Not Home*
  • Would you like documents sent by mail?

  • Service availability

  • Tick AM, PM, and/or All day for each day the client can receive services.

    • Use Other for free-text notes (e.g. after 3pm only).
    • Capture the client's usual preferred windows — not a confirmed roster.
  • Service Availability (Days and Times)*
    Rows

  • Goals and preferences

  • Capture at least one client goal. Preferences and property notes are optional but help support workers deliver safe, person-centred care.

  • Submit Financial Hardship Claim*
  • CHSP Fees and Contributions Acknowledged*
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  • Data Exchange privacy and consent

  • Staff: Read or paraphrase this section to the client before recording their answers.

    We collect some personal details on this form. Personal information is protected by law, including the Commonwealth Privacy Act 1988 (Cth).

    Caura uses the Data Exchange (DEX), run by the Australian Government Department of Social Services (DSS), to manage client details and CHSP services. DSS stores information in the Data Exchange and only shares identifiable details with Caura so we can manage services.

    More information: dex.dss.gov.au and the DSS privacy policy.

  • Consent to store name and address in the Data Exchange

  • Their Data Exchange record can include their name (or a pseudonym) and street address. They do not have to agree.

    • If they choose not to agree, reporting continues without those identifiers and services are unaffected.
    • They can ask later to remove this information from the Data Exchange.
    • DSS uses de-identified (anonymous) information for policy, grants, research and evaluation — personal details are removed so they cannot be identified.
  • Does the client consent to their name (or a pseudonym) and/or street address being stored in the Data Exchange?*

  • Consent to follow-up research and surveys

  • Separately from storing name and address, ask whether they are willing to be contacted for follow-up research, surveys or evaluation about the services they receive.

    • This is a Data Exchange priority reporting item.
    • It is voluntary and is not the same as consent to store personal details in DEX.
    • Saying no does not affect access to services.

  • Acknowledgement

  • Record the client's answers for DEX reporting. Use the option that best matches their usual situation.*

  • Disability

  • Do you live with any disabilities?*
  • Which disability types apply?*
  • Is the name recorded for this client a pseudonym?*
  • Is the client's date of birth an estimate?*
  • Does the client have a carer?*

  • SAH package and classification

  • Capture My Aged Care identifiers, funding classification (levels 1–8, interim/restorative, or not yet assessed), and whether this is a new package or a transfer.

    Upload the current My Aged Care Client Snapshot at the end of this page before collecting remaining SAH details.

  • MAC and classification

  • MAC Expiry Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Funding Classification*
  • Is This an Interim Package?
  • Awaiting Higher Level Package*
  • Higher Support at Home Funding Classification*

  • Transfer

  • Other

  • Would you like documents sent by mail?
  • Previously Offboarded by Caura
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  • SAH services required

  • Select the Support at Home service types the client needs, grouped by means-testing category. Selections inform care planning and prefill the service agreement schedule.

    • Clinical Supports — typically 0% participant contribution.
    • Independence and Everyday Living — contribution rates depend on the means assessment.

  • Everyday living

  • Everyday Living

  • Independence

  • Independence

  • Clinical supports

  • Clinical Supports

  • Availability, commencement and care plan meeting

  • Capture preferred service windows, commencement date, quarterly budget, and who will attend the initial care plan meeting.

  • Scheduling and care plan

  • Service Availability (Days and Times)*
    Rows
  • Service Availability (Days and Times) — Other notes
    Rows
  • Preferred Commencement Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Who Will Attend the Initial Care Plan Meeting?

  • SAH representative and consents

  • Capture how the package is managed, the My Aged Care authorised representative (if any), and scoped information-sharing / act-on-behalf consents.

  • Package management

  • MAC Portal Authorised Representative Registered*
  • Is the MAC-Registered Representative the Same Person as in M1?*
  • Format: 0000000000.

  • Care partner

  • Representative Consent — Information Sharing*
  • Representative Consent — Act on Behalf*

  • SAH health and clinical

  • Collect medication, health summary, GP, hospital, and palliative care details for the enrollment clinical profile.

  • Medications

  • Takes Medication to Manage Health*
  • Medications Accurate in Health Summary*
  • Takes Anti-clotting Medication
  • Medications Cause Drowsiness
  • Takes Blood Pressure Medication
  • Requires Help to Take Medications*
  • Uses Webster Pack
  • Medication Errors in Last 6 Months

  • Health summary

  • Has Medical Health Summary
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  • Medical Conditions Correct in Health Summary
  • Does the client have a diagnosis or other medical condition relevant to support?*

  • GP

  • Format: 0000000000.

  • Hospital and palliative care

  • Last Hospital Admission
  • Managed by Palliative Care Team
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  • SAH fees and finance

  • Capture pension status, means assessment, income-tested care fee, payment preference, and hardship application status.

  • Means testing and fees

  • Pension Status
  • Income or Means Assessment Completed*

  • Payments and hardship

  • SAH person-centred profile

  • SAH person-centred profile

  • Optional context for person-centred care planning — interests, values, strengths, and staff preferences.

  • Life context

  • Staff preferences

  • SAH technology

  • Optional notes on comfort with technology, online banking, and whether the client has a technology support person.

  • Can Use Online Banking
  • Has Technology Support Person

  • Declaration

  • NDIS Orientation — rights, complaints, emergency and privacy information have been explained*
  • NDIS Orientation — paperwork and contact information have been provided*

  • Signature

  • Signing As*
  • Should be Empty: