Client Intake - Participant Assessment and History

Participant Assessment and History
Assessment date

DayMonthYear
DateHourMinutesAM/PM Option
Assessor's Name:

First NameLast Name
Assessor's Email
example@example.com
Participant Details
Participant Name:

PrefixFirst NameLast Name
Preferred Name:
(If applicable)
Date of Birth:

DayMonthYear
Date
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Best Contact Number:

Area CodePhone Number
Email address
example@example.com
Medicare No.:
Centrelink No.:
NDIS Number:
Country of Birth:
Does the Participant identify as an Aboriginal or Torres Strait Islander?

YesNo
Does the Participant have a Primary Representative?

YesNo

Pain management strategies:

NoneAnalgesicsHeat packsPosition changeMassageOther
How often:
Does the Participant need additional assessment or follow up by a health professional?

YesNo
Recommended health professional:
Additional Information:

Behaviour Management
Does the Participant have any behaviors of concern ?

YesNoI am concerned
Is there a current Behaviour Support Plan?

YesNo
Attach Behaviour Support Plan

Browse Files

Cancelof
Please obtain a support plan from a specialist/health professional.
What does the behavior look like?
How is the behavior currently managed?
Known triggers/frequency:
Emotional support/strategies for Participant:
Emotional support/strategies for carer:
Does the Participant need additional assessment or follow up by a health professional?

YesNo
Recommended health professional:

Is there any other report or relevant information included in this assessment?

YesNo

Photo or browse and upload additional information

Browse Files

Cancelof
Any other precautions or information to advise in relation to Participant's condition or planned service provision?
Assessor comments on the information collection process (more than one option can be chosen)

participant and/or representative declined to provide some/all of the information requested and deemed relevant for provider to be aware of or relevant to the planned service provisionsome information is unlikely to be relevant to the planned service provision (if relevant at a future date, it will be followed-up and provided)some information required was not available at the time of this assessment - it will be followed-up and assessor has been advised will be made availablesome information requires further assessments/reports yet to be completed or made available by other clinical/allied supports
Additional comments in relation to the comments above or information collection process
Participant's main Representative's name (who participated in this assessment):

First NameLast Name
Participant/Representative's Signature over Printed Name

Clear
Assessor's Signature over Printed Name

Clear
Should be Empty: