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Geelong

Intake

Participant in-take

"*" indicates required fields

1. Services required

Please tick all that apply*

Support coordination level 2

Assistance with self-care activities including SIL

Access community social & rec activities

Innovative community participation

Group activities

STA

MTA

Individual social skills development

2. Participant details

Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Date of Birth*

DD slash MM slash YYYY

Contact phone number*

Contact email*

Language spoken at home

Interpreter required*

Yes

No

Companion card holder*

Yes

No

Companion card number*

Preferred option for communication*

Email

Phone call

Post

SMS

Video call

Face to face

Do you identify as Aboriginal or Torres Strait islander?*

Yes

No

Is there a guardianship and/or administration order in place?*

Yes

No

Please provide details*

Is there a behaviour management plan in place?*

Yes

No

Is the participant under the age of 18 years of age, under guardianship or in the care of family or caregivers?*

Yes

No

Parent/Guardian 1 details

Parent/Guardian 1 name*

Relationship to participant*

Parent

Guardian

Caregiver

Other

Emergency contact*

Yes

No

Lives with participant*

Yes

No

Primary carer*

Yes

No

Your phone number*

Your email*

Residential address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your postal address the same as your residential address?*

Yes

No

Postal address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you wish to include a second parent/guardian?*

Yes

No

Parent/Guardian 2 details

Parent/Guardian 2 name

Relationship to participant

Parent

Guardian

Caregiver

Other

Emergency contact

Yes

No

Lives with participant

Yes

No

Primary carer

Yes

No

Your phone number

Your email

Residential address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your postal address the same as your residential address?

Yes

No

Postal address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3. Disability/medical condition including any relevant diagnosis / allergies /asthma/epilepsy

1.*

2.

3.

Behaviour Support Plan documents collected for authorisation purposes (if relevant)*

Yes

No

Behaviour Support Plan available on NDIS portal?*

Yes

No

4. Other service providers currently using (include Specialist Behaviour Support Provider, if relevant) Occupational therapist, speech pathology, psychology, physiotherapist.

Service provider 1 name

Phone

Email

Frequency of use

Service provider 2 name

Phone

Email

Frequency of use

Service provider 3 name

Email

Phone

Frequency of use

5. Health care information

Medicare number*

Expiry date*

Reference number*

Doctor name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number*

6. NDIS Details

NDIS number*

NDIS plan date: from*

DD slash MM slash YYYY

NDIS plan date: to*

DD slash MM slash YYYY

Plan management type

Agency managed

Plan managed

Self-managed

Please provide details for invoices:

Name*

Email*

7. Preferences

Preferred name*

Religious requirements*

Cultural requirements*

Communication device*

Physical assistance*

Other considerations (likes/dislikes)*

Worker preference*

Male

Female

Either

8. Goals and aspirations

What do you want to achieve for yourself - life skills, physically, socially etc?

Immediately*

In 6 months*

Next year*

I understand that:

These records are owned by this organisation.
Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
I can ask to see records and receive a copy
Records are archived for a set period according to policy and procedure
I understand that all information obtained will be kept confidential.

To the best of my knowledge, the information provided in this form is true and correct:

Participant signature or Parent /caregiver signature*

Name of person signing **

Relationship to the participant, if not the participant*

Note: Authority to Act as an Advocate form is required if the individual signing this form is not the participant.

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Contact

11/147 Marshalltown Rd

Grovedale VIC 3216

ua.moc.sgumelggig@ofni

Hours

Monday 9:00am - 5:00pm
Tuesday 9:00am - 5:00pm
Wednesday 9:00am - 5:00pm
Thursday 9:00am - 5:00pm
Friday 9:00am - 5:00pm
Saturday Closed
Sunday Closed

Information

Feedback
Third party information
Privacy statement
Intake
Privacy

Registered NDIS provider

NDIS provider number 4050129764

Gigglemugs Ability Provider acknowledges the Wadawurrung Traditional Owners on the land of which our business stands. We pay our respect to elders past, present and emerging.

Websites Geelong GOOP Digital

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