• A colourful abstract logo featuring four interlocking heart-like shapes in red, grey, dark blue and light blue, arranged symmetrically around a central point, with a matching coloured circle at the outer end of each shape

  • Client Intake Form

    Home Alone Support Services

  • 1. Client Details

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you require an interpreter*
  • Preferred option for communication*
  • Do you identify as Aboriginal and Torres Strait Islander?*

  • 2. Health Care Information

  • Expiry Date:*
     - -
  • Format: (000) 000-0000.

  • 3. Funding

  • Funding type*
  • Funding Management Option*
  • A colourful abstract logo featuring four interlocking heart-like shapes in red, grey, dark blue and light blue, arranged symmetrically around a central point, with a matching coloured circle at the outer end of each shape
  • Please provide details for invoices

  • 4. Preferences

  • 5. Risk Assessment

    See seperate form
  • Home Safety Risk Assessment Completed*

  • I understand that:

    • Home Alone Support Services owns these records.
    • Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
    • I can ask to see records and receive a copy
    • Records are archived for a set period according to policy and procedure
    • I understand that all information obtained will be kept confidential.

    To the best of my knowledge, the information provided in this form is true and correct:

  • Date:*
     - -

  • Note: Authority to Act as an Advocate (Client Consent Form) is required if the individual signing this form is not the client.

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  • Should be Empty: