Intake / Referral for Decluttering & Organisation Services
Your / referrer name
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Referring organisation
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Your / referrer phone
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Your / referrer Email
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Client First Name
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Client Last Name
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Preferred Pronouns
She /Her
He/ Him
They / Them
Other
If Child - Name NOK / guardian
Client Phone
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Client Participant/ Reference or NDIS Number
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Client Address
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Suburb
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Postcode
State
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For booking and initial zoom / phone consultation
Please contact client to book
Please call referrer to book
What space or spaces would you or you client like assistance with?
Whole House
Play space
Pantry only
Linen cupboard only
Art / craft space
Office /Study
Administration / paperwork
Shed / Garage
Laundry room
Other
Please share more information about the support you or your client are seeking. What would be an ideal goal or outcome from engaging our services?
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For a more accurate quote, you may like to attach some pictures of the proposed area with draws and cupboards open. Or we can see what we can get through on the day.
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Is there anything else you would you like us to know?
Emergency Contact Person
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Relationship to Emergency Person
Emergency Contact Number
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Is funding being provided by any of the following?
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DVA
DFFH
NDIS
Homecare
Baptcare
Other
If NDIS funded please identify where these services will fit within your or your clients plan goals for invoicing. If plan managed please ensure that your plan manager has given approval for services prior to confirming a booking.
Capacity Building: Improved Daily Living Skills (15_056_0128_1_3 Assessment Recommendation Therapy or Training - Other Professional)
Capacity Building: Increased Social and Community Participation (09_008_0116_3 Innovative Community Participation) Suitable for participants at risk of isolation.
Core Supports: Assistance with Daily Life (01_027_0115_1_1 Assistance in a Shared Living Arrangement)
Core Supports: Assistance with Social, Economic & Community Participation (04_210_0125_6_1 Community Social and Recreational Activities)
Other
Please email invoices to
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Please read the attached Service Agreement which includes our cancellation policy.
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Are there any safety hazards we should be aware of? Please click on all that are applicable.
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Pests - Mice, moths, cockroaches or the like
Piles of items/ belongings higher than waist height
Firearms or weapons
Smoking - cigarette, vape or other substance
Current renovations
Asbestos
Pets who may become aggressive
Significant piles of rubbish on the floor
Mouldy items or furniture
Mould in fridge and mouldy food
Human or animal waste such as faeces, urine, vomit or blood
Water damage, unstable flooring, significant building deterioration
None of the above
If you ticked any of the boxes above, please describe in more detail.
How did you hear about JMC's Decluttering and Organising service?
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Friend/ Family
Google Search
Social Media
Networking
Podcast
Newspaper/ Magazine
NDIS Support Coordinator/ Plan Manager
Other
Is there anything else you'd like to share?
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