Intake FormA problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator. Refferal Details Date of Referral: New Participant Returning Participant Non-urgent Urgent Reffered by: Contact Number: Email: Participant Details Family name: Given Name: Preferred Name: NDIS Number: NDIS Plan Start Date: NDIS Plan End Date: NDIS Plan NDIA ManagedPlan ManagedSelf Managed Email Invoices to: Plan Manager's Organisation/Plan Manager Organisation Name Privacy Policy Explained - Consent gained: Verbal consent (phone) Consent (in-person) Date of Birth Gender Male Female Not Stated Country of Birth: Interpreter Yes (Language) NoContact Details Address: Postal Address: Mobile Work Phone: Email: Preffered contact method: Carer/Family Details/Next of Kin Name: Relation to participant: Phone: Email: Services/supports requested Service/ Supports: Plan Management Support Coordinator Core Supports Capacity Building Supported Independent Living (SIL) Specialist Disability Accommodation (SDA) Days/Hours: Specific requirements/preferences If modifications to existing facilities or processes may be required, describe here: Participant’s Information:1. Behavioural Yes No 1.1 Screaming Bis PlanYNN/A 1.2 Hitting others Bis PlanYNN/A 1.3 Pinching others Bis PlanYNN/A 1.4 Kicking others Bis PlanYNN/A 1.5 Self-harm MildModerateExtremeYNN/A 1.6 Sexualized behaviours YNN/A 2. Medical Yes No 2.1 Epilepsy MildModerate;Extreme;YNN/A 2.2 Medication OralInjectionSkinYNN/A 2.3 Diabetes Type 1TypeDaily BSLYNN/A 2.4 Peg Feed YNN/A 2.5 Tracheotomy YNN/A 2.6 Mental Health ControlledUncontrolledYNN/A 2.7 Asthma MildModerateExtremeYNN/A 2.8 Choking Risk MildModerateExtremeYNN/A 2.9 Allergy YNN/A 3. Mobility Yes No 3.1 Wheelchair Fits through doorsYNN/A 3.2 Can transfer from wheelchair to van with little assistance YNN/A 3.3 Can transfer from wheelchair to bed with little assistance YNN/A 3.4 Can transfer from wheelchair to shower with little assistance YNN/A 3.5 Can climb stairs YNN/A 4. Personal Care Yes No 4.1 Bathing NonePromptingFull AssistanceYNN/A 4.2 Toileting NonePromptingFull AssistanceYNN/A 4.3 Dressing NonePromptingFull AssistanceYNN/A 4.4 Appearance NonePromptingFull AssistanceYNN/A 5.Mealtime Yes No 5.1 Diet UnrestrictedRestrictedYNN/A 5.2 Food Texture UnrestrictedABCYNN/A 5.3 Fluid Texture UnrestrictedMildModerateExtremeYNN/A 6. Likes and Dislikes Yes No 6.1 Likes to spend time in groups YNN/A 6.2 Gets anxious at new places YNN/A 6.3 Gets anxious with loud noises YNN/A 6.4 Get anxious with crowds YNN/A 6.5 Likes swimming YNN/A 6.6 Likes Rugby League Games TVAt gameAt clubYNN/A 6.7 Enjoys eating in restaurants/clubs YNN/A 6.8 Likes parks YNN/A 6.9 Likes the beach YNN/A 6.10 Likes animals YNN/A 6.11 Likes movies TVCinemaOutdoorYNN/A 6.12 Likes markets YNN/A 6.13 Can handle money PromptingFull AssistanceYNN/A 6.14 Has Companion Card YNN/A 7. Communication Yes No 7.1 Communicates independently YNN/A 7.2 Communicates with prompts YNN/A 7.3 Non verbal YNN/A 8. Community Access and group activities Yes No 8.1 Safety Awareness YNN/A 8.2 Road safety YNN/A 8.3 Following instructions YNN/A 8.4 Staying in a group or carers YNN/A Does the person have a Behaviour Support Plan? ---Select---YesNo Is a copy attached? ---Select---YesNo Name of Psychologist Organization Does the person require support to regulate behaviours such as verbal/physical aggression, self-injury, sexualized behaviours, property damage, absconding? Does the person have a Communication Plan? ---Select---YesNo Is a copy attached ---Select---YesNo Name of Speech Therapist Organization Does the person have an Occupational Therapy Plan? ---Select---YesNo Is a copy attached ---Select---YesNo Participant Profile Participant goals Participant disabilities: Current behaviours of concern: Participant’s current support needs: Participant support needs history: Participant informal and other supports (if any): Participant mainstream supports (if any): Participant decision maker: Participant Outcomes: Outcome How will this be measured What does success look like Reason Details Discussion Checklist Right to have a support person present Right to engage an Advocate Entry and Exit procedures Eligibility and priority of access Conditions that may apply to service Fees including any associated costs NDIS Complaints/ Incidents/Risk Management processes Comments Assessment Interview Planning Date: Time: Address ---Select---Participant’s home:Another venue: Address Specific instructions re: venue Attendees: Supporters – Family, friends, carers Other Service Providers Advocate Interpreter Participant’s communication preferences Intake completed by: Name: Date Signature ❌ How did you hear about us? Social MediaGoogle/ BingWord of mouthOnline advertisementsOther Send
