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Participant in-take

1. Participant details

DD slash MM slash YYYY
Interpreter required
Preferred option for communication
Do you identify as Aboriginal and Torres Strait Islander?
Is there a Guardianship and/or Administration Order in place?
Is there a Behaviour Management Plan in place?

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below:
Primary carer
Emergency contact
Lives with participant
Relationship to participant

Primary carer
Emergency contact
Lives with participant
Relationship to participant

2. Disability / medical conditions including any diagnosis (if relevant)

Behaviour Support Plan documents collected for authorisation purposes (if relevant)
Behaviour Support Plan available on NDIS portal?

3. Services requested

Community participation, in-home support, respite?

4. Other service providers currently using (include specialist behaviour support provider, if relevant)

5. Health care information

DD slash MM slash YYYY

6. Funding

DD slash MM slash YYYY
DD slash MM slash YYYY
Managed
Please provide details for invoices:

7. Preferences

8. Goals and aspirations

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

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

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