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Geelong
0492 984 654
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Participant in-take
1. Participant details
Participant name
Gender
Date of Birth
DD slash MM slash YYYY
NDIS number
Phone
Mobile
Email address
Language spoken at home
Residential address
Postal address (if different from above)
Interpreter required
Yes
No
Preferred option for communication
Email
Post
Phone
Do you identify as Aboriginal and Torres Strait Islander?
Yes
No
Is there a Guardianship and/or Administration Order in place?
Yes
No
Is there a Behaviour Management Plan in place?
Yes
No
For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below:
Name of parent guardian 1
Primary carer
Yes
No
Emergency contact
Yes
No
Lives with participant
Yes
No
Relationship to participant
Parent
Guardian
Caregiver
Other
Residential address
Postal address (if different from above)
Phone
Mobile
Email address
Name of parent / guardian 2
Primary carer
Yes
No
Emergency contact
Yes
No
Lives with participant
Yes
No
Relationship to participant
Parent
Guardian
Caregiver
Other
Residential address
Postal address (if different from above)
Phone
Mobile
Email address
2. Disability / medical conditions including any diagnosis (if relevant)
1.
2.
3.
Behaviour Support Plan documents collected for authorisation purposes (if relevant)
Yes
No
Behaviour Support Plan available on NDIS portal?
Yes
No
3. Services requested
Community participation, in-home support, respite?
1.
2.
4. Other service providers currently using (include specialist behaviour support provider, if relevant)
Service provider 1 name
Address
Phone
Email
Frequency of use
Service provider 2 name
Address
Phone
Email
Frequency of use
Service provider 3 name
Address
Email
Phone
Frequency of use
5. Health care information
Medicare number
Expiry date
DD slash MM slash YYYY
Reference number
Private healthcare provider
Membership number
Reference number
Doctor name
Address
Phone
6. Funding
NDIS number
NDIS plan date: from
DD slash MM slash YYYY
NDIS plan date: to
DD slash MM slash YYYY
Managed
Self-managed
Plan managed
Agency managed
Please provide details for invoices:
Name
Comments
Email
7. Preferences
Preferred name
Religious requirements
Cultural requirements
Communication device
Physical assistance
Other considerations (likes/dislikes)
8. Goals and aspirations
What do you want to achieve for yourself - life skills, physically, socially etc?
Immediately
Next year
In 6 months
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
Name of person signing
Relationship to the participant, if not the participant
Date
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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Home
Services
Community participation
Support coordination
In-home support
Short term accommodation
Respite
Domestic assistance
High intensity support
News
About
Contact