Client Intake Form NDNS 2026

Client Intake Form NDNS 2026
Before you Begin

Before completing this referral, please note that NDNS:
- provides services to adults aged 18 years and over
- generally does not provide regular overnight services
- provides services across Newcastle, Lake Macquarie, the Lower Hunter, and the Forster–Taree area
If you are unsure whether the client is within our service area or whether we can provide the support required, please contact NDNS before completing this form.

This form will take approximately 20 minutes to complete.

You can complete the form on a phone or tablet; however, you may find it easier to complete on a laptop or desktop computer.

If you are completing this form on behalf of someone else, we recommend having them with you or available by phone so you can check any information you are unsure about.

Before you start, please have the following information available where applicable:
- Details about the client, including their current living situation
- A copy of any Power of Attorney or other decision-making documents, if available
- My Aged Care referral codes for the services being requested
- DVA client number, if applicable
- Copies of any care plans, treatments plans or health assessments as relevant
Don't worry if you don't have all of this information.

Please complete the form as best you can, and a member of our team will contact you if we need any further information or clarification.

About the Person Completing the Form
I am completing this form:
Your Name

First NameLast Name
My relationship to the person who requires care services is:
Please Specify if Other
Organisation represented
My Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Is the client or their responisble person aware of the referral to NDNS?

Client Details
Title (Optional)
Client Name

First & Middle Name/sLast Name
Preferred Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
What was your (the clients) gender recorded at birth
Required for clinical screening & medical history
How do you describe your (the clients) gender identity?
Required to help us provide patient-centred care
Please specify
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clients best Contact Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Email Address
example@example.com
Do you (the client) identify as Aboriginal or Torres Strait Islander?
What Country were you (the client) born in?
Country of Birth if Other selected
What language do you / the client mostly speak at home?
Language if Other selected
Is an interpreter required to discuss health matters?
Do you (the client) have health insurance cover including ambulance cover?
Who is your Provider?

Aged Care Funding
My Aged Care (MAC) Number
Please enter the client’s 8-digit My Aged Care number which starts with AC
I have code/s approvals for;
Support at Home referral Code
Please enter the client’s Support at Home referral code. This can be found in their My Aged Care information or provided by My Aged Care.
I have been approved for;
CHSP Nursing referral Code
Please enter the client’s My Aged Care referral code for Nursing. CHSP referral codes are specific to the approved service.
CHSP Co-payment

Clients are required to contribute $10 each time a CHSP service is provided, up to a maximum total contribution of $40 per week.

Our preferred payment method is direct debit; however, payment can also be made by direct deposit.
I have another source of funding I would like NDNS to provide support through
As well as aged care i have funding through;

ICare or Other Insurance

Includes Lifetime Support, Dust & Diseases Board, Workers Insurance, CTP
Claim Number
Funding Type
Case Manager / Coordinator
Case Manager / Coordinator Phone
Please enter a valid phone number.Format: (00) 0000-0000.
Case Manager / Coordinator email
example@example.com
Please attach a copy of the Service Approval

Cancelof
I have another source of funding I would like NDNS to provide support through
As well as ICare/Insurance i have funding through;

Private Services

As a privately paying client, you are responsible for the cost of all services provided by NDNS. Invoices are issued monthly and are payable in accordance with the payment terms outlined on your invoice.

For information about our current private service fees, please refer to our Schedule of Fees on the NDNS website.

Our preferred payment method is direct debit; however, payment can also be made by direct deposit to NDNS.
Confirmation
I have another source of funding I would like NDNS to provide support through
As well as paying privately i have funding through;

Subcontracting
Company Represented
Case Manager / Coordinator Name
Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Email
example@example.com

Other Funding

Any funding not covered by Aged Care, NDIS, ICare / Insurance, DVA or Private payment
Other Funding

Please provide all relevant details such as;
- Funding name
- Best Contact person
- Best Contact Phone Number
- Best Contact Email
Details

Consumables
Consumables are care-related products and supplies that are used regularly or need to be replaced as part of your care.

Examples include:
- Continence products (pads, pull-ups, liners)
- Wound care products and dressings
- Catheter or urinary supplies
  Stoma supplies
- Diabetes supplies
- Enteral feeding/PEG supplies
- Skin protection or pressure care products
- Personal protective or clinical supplies
- Other care-related consumables
As part of your care do you require the ordering of consumables or clinical supplies on your behalf?
Who is / will be responsible for ordering consumables?
Are there any funding limitations or special conditions or budget amounts to be aware of when ordering consumables?
Please provide details.

Doctors
Working collaboratively with your healthcare team

To support safe, coordinated care, NDNS works collaboratively with your GP, specialists and other health professionals involved in your care. Providing your doctor’s details allows our clinical team to communicate with them when needed about your care, medications and any changes in your health.

If you require NDNS workers to administer or supervise medications, or administer injections, we will also need a current medication chart completed by your prescribing doctor. This may be your GP or treating specialist.
To support coordinated care, do you give NDNS permission to contact your doctor about your health care, including requesting medication charts when required?
Doctors Name
Medical Practice Name
Doctors Suburb
Doctors Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Other Providers
You may wish to provide details of your existing providers. e.g Physio, EP, Dietician, Psychologist, Specialist. Please provide their name, occupation, location and phone number. If there is not suffient space here you can advise our intake officer when we speak with you.

Follow Up Information & Declaration
What happens next?

Once your referral has been submitted, a member of the NDNS team will review the information provided and contact you within 2 business days to discuss your referral and next steps.

If your referral is urgent or you need to speak with someone sooner, please call our office on 02 4953 8444.

Please note that submitting a referral does not guarantee that NDNS will be able to provide the requested services. Service availability will depend on your individual needs, funding, service requirements and our current capacity.
Please note the Following;

Fees and charges – acknowledgement that fees, co-payments or client contributions may apply depending on the funding program, with a reference to your Schedule of Fees.

Information may need to be verified – NDNS may contact the client, representative, referrer or relevant health professional to clarify information provided.

Worker allocation – NDNS allocates workers based on client needs, worker skills, availability and service requirements. Specific workers, times or worker characteristics cannot generally be guaranteed.

First Aid - NDNS workers carry basic first aid supplies, including some wound care products.

If you require first aid during a service and any of these supplies are used, the cost of the items may be charged to your available funding or directly to you, depending on your funding arrangements.

Agreed services only – workers can only provide services that have been assessed, agreed and included in the care plan/service arrangements. This ties nicely into your Domestic Assistant paragraph.

Domestic Assitance - Domestic Assistants can only complete tasks that have been agreed upon as part of your services and documented in your care plan. For the safety of both you and our workers, Domestic Assistants cannot undertake tasks involving heavy lifting, working at heights, outdoor work, gutter cleaning, or other tasks that may present an unreasonable safety risk.

If you need help with a task that is not included in your agreed services, please contact NDNS so we can discuss your needs and whether alternative support can be arranged.

Domestic Assistance services are provided Monday to Friday only and are not available on weekends or public holidays.

Service days and times are subject to worker availability and will be discussed with you before services commence.

Emergency disclaimer – NDNS is not an emergency service. If you require urgent medical assistance, call 000.
Declaration
Should be Empty:

Client Intake Form NDNS 2026

About the Person Completing the Form

Client Details

Current Services & Support

Social Supports

Reason for Referral

Aged Care Funding

National Disabilty Insurance Scheme (NDIS) Funding

DVA - Community Nursing & Veterans Home Care

ICare or Other Insurance

Subcontracting

Other Funding

Environment Assessment

Mobility & Manual Handling

Communication Needs

General Health

Complex or High Intensity Clinical Care

Consumables

Doctors

Other Providers

Client Usual Living Arrangement

Client Decision Making & Capacity

Other Communication & Emergency Contact

Follow Up Information & Declaration