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PARTICIPANT INTAKE FORM

General Information

Participant first name *

Participant surname *

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 *

Confirmation Of Plan Management Type (For Support Coordination and/or Psychosocial Recovery Coaching) *

Self ManagedPlan Managed Agency ManagedUnsure

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 Attourney/Gaurdianship 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 dietry requirements i.e vegeterian/vegan

Your Disability / Impairement

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 (if applicable)

Speech Therapist Name and Contact (if applicable)

Occupational Therapist Name and Contact (if applicable)

Physio Therapist Name and Contact (if applicable)

Psychologist/ Counsellor Name and Contact (if applicable)

Other Therapist Name and Contact (if applicable)

Your needs

Do you have a preffered gender/personality type to be taken into consideration when chosing 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 refferals 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