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PARTICIPANT INTAKE FORM

General Information

Participant Full Name *

Date of birth *

Email Address *

Home phone

Mobile phone *

Home address *

How did you find out about us? *

Emergency Contact / Representative Information

Name of Emergency Contact / Representative *

Phone *

Relationship to you *

Date of Birth *

Your NDIS Information

Your NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Services you are requesting *

Support CoordinationPsychosocial Recovery CoachingCounsellingArt Therapy

Confirmation Of Plan Management Type for requested services *

Self-ManagedPlan Managed Agency ManagedUnsure

Please confirm email address to where invoices will be sent *

Please note: COSY requires confirmation of available funds prior to commencing services.

We are unable to provide service to Agency Managed participants.

Medical Information

Name of GP or treating doctor *

Contact number *

Address *

Please list any medications you are taking

Name of medication/dosage

Please list any allergies

Type of allergy, symptoms and required interventions

Living arrangements

About You

Are you of indigenous culture? *

Aboriginal but not Torres Strait Islander originTorres Strait Islander but not Aboriginal originBoth Aboriginal and Torres Strait Islander originNeither Aboriginal or Torres Strait Islander originPrefer not to answer

Do you have a legal power of Attorney/Guardianship involvement? *

Do you have an NDIS listed nominee? *

Do you have any involvement with DHHS/Child Protection or other government agencies of relevance? *

Do you have any legal interventions/orders/pending matters of relevance? *

Do you smoke? *

YesNoI used to smokePrefer not to say

Do you use recreational drugs? *

NoI have previously usedI currently usePrefer not to say

Do you attend school/employment *

Name of School or employer if listed above

What are your interests/hobbies? *

What are your triggers/ things you dont like? *

What are you comforts or things that make you feel calm and happy? *

Please list any dietary requirements i.e vegetarian/vegan

Your Disability / Impairment

Primary funded disability *

Please list any other disabilities / impairments

What are your main goals? *

Are these goals listed in your current NDIS plan? *

Please provide detailed information for each area selected above *

Your providers

Please ensure you include a contact number or email for each provider

Care provider i.e. Company or Individual support (or NA if not applicable) *

Speech Therapist Name and Contact (or NA if not applicable) *

Occupational Therapist Name and Contact (or NA if not applicable) *

Physio Therapist Name and Contact (or NA if not applicable) *

Psychologist/ Counsellor Name and Contact (or NA of not applicable) *

Other Therapist Name and Contact (or NA if not applicable) *

Your needs

Do you have a preferred gender/personality type to be taken into consideration when choosing your care team i.e. male support workers/female therapist * *

Is there any other information you would like us to know? *

Consent

Do you give consent for this information to be shared with third parties, where necessary, to complete new referrals on your behalf? * *

YesNo

I confirm that above information I have provided is true, complete and accurate. *

Client/Representative Name *

Client/Representative Signature *

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Date