The DARE Project Intake Form

1
Your DetailsPerson completing this form
Your Full Name
Relationship to the client
Best contact number
Your email address
Please Select
Please Select
I am authorised
Authorisation to provide details.
2
Personal DetailsPart 1
Full Name
Gender
Date of Birth
Address
NDIS Reference Number
NDIS Plan Dates
Preferred Language
Please Select
Please Select
YES
NO
Interpreter Required
3
Personal DetailsPart 2
Please Select
Please Select
Alone
Family/Partner
Supported Accommodation
Other
Living Arrangement
Living Arrangements: Other (Please Specify)
Please Select
Please Select
Yes
No
Does the client identify as an Aboriginal or Torres Strait Islander?
If yes, please specify
Please Select
Please Select
Yes
No
Does the client identify as Culturally and Linguistically Diverse (CALD)?
Please Select
Please Select
Self Managed
Plan Managed
NDIA Managed
No NDIS Plan
I'm not sure
NDIS Management
What are the clients goals?
4
Referral Details
Name of Organisation (if applicable):
Referrer Name + Phone Contact
Please Select
Please Select
Family Member
Support Coordinator
Case Manager
LAC
Other
Job Title/Role
Email Address
Alternate Contact (if applicable)
Relationship to Client
Please Select
Digital LABs
Adventure LABs
Football LABs
Other
Primary Reason for Referral?
Primary Reason (Other)
5
Client Contact Preferences
Clients Preferred Contact Person
Relationship to Client
Please Select
Please Select
Phone Call
SMS
Email
Other
Clients Preferred Contact Method
Preferred Contact Details
Any other details?
Should be Empty: