Medical Intake form

Client Intake form
Name

First NameLast Name
Person Filling Out This Form (if not the Patient)

First NameLast Name
Relationship to the Patient
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Country of Birth
Gender
Sexual Orientation?
Preferred language?
YesNo
YesNo
Marital Status
Client’s occupation
Living Situation
NDIS Number
Plan Manager
NDIS Plan Start Date

DayMonthYear
Date
NDIS Plan End Date

DayMonthYear
Date
Received a copy of the NDIS plan?
Current services in place
Other unmentioned services in place
Medical Health Condition
Mental Health Condition
Please list any significant physical trauma you've experienced
Please list emotional trauma you've experienced in your life
Client Signature

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Date

DayMonthYear
Date
Collection of Personal Information and Consent

Correct Connect collects and retains personal information (such as your name, date of birth, address and personal needs ) so that we may provide you with services. This information may be disclosed between the NDIA and its partner agencies and other service providers that may be able to provide you with support services. Unless authorised or required by law, your personal information will not otherwise be disclosed to any other third party without your consent. Correct Connect Privacy Policy can be provided on request.
Staff will only collect relevant personal information to:
- provide quality services
- carry out the functions, supports and activities on behalf of the organisation
- meet our statutory, licencing, regulatory or legal requirements
Staff shall not disclose or use personal information without the consent of the individual and/or appointed guardian/administrator without the
specific written consent of the customer/guardian.

I consent for Correct Connecty to collect the above personal information and to create service bookings on my behalf as the client (for NDIS/Agency-managed plans only).
Name of Client {name} or
Client Representative {personFilling}
Signature {clientSignature}
Date {date}

If you require support completing this form, please contact our team on 0439 334 995 or email fiona@correctconnect.com.au
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Client Intake form