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Participant Intake/Referral Form

Participant Details:

First name*

Last name*

Birthday*

Day

Month

Year

Gender:*

Female

Male

Non-binary

Prefer not to say

Email*

Phone*

Address*

Emergency Contact (name, relation, contact details)*

NDIS Funding Information:

NDIS Number:*

Start date of NDIS plan*

End date of NDIS plan*

Type of NDIS Funding:

Multi choice*

Self Managed

Plan Managed

NDIA Managed

Contact details for invoices (if applicable - name, email, phone)

Diversity and Cultural Background

*

Aboriginal

Torres Strait Islander

Both

Neither

Preferred Language *

Interpreter/Translator or Communication aids required?*

Yes

No

Health Information

Primary disability/disabilities & health issues:*

Allergies (if any)*

Medications (if any)*

Assistance with medication required?*

Yes

No

Supports Required:

Select all that apply:*

Community Nursing Support

Therapeutic Support

In-home Support

Assistance with Daily Tasks

Support with Personal Activities

Assistance with Life Stage Transitions

Support to Participate in the Community

Development of Life Skills

Transport Support

Desired Hours, Days, Support Worker Preference (age, gender, culture):*

Are you referring yourself?*

Yes

No

If no, what is your relationship to the patient?

Support Coordinator

Case Manager

Local Area Coordinator

Family

Friend

Other

Who is the Primary Contact for this referral?*

Participant

Support Coordinator

Family

Other

If the Primary Contact is NOT the Participant, please provide contact details below (name, relation, phone, email):

Is the Participant currently affiliated with another service provider?*

Yes

No

If yes, what is the reason for changing? (if you mind sharing)

Is anyone at your/the clients property, known to be aggressive or violent?*

Yes

No

Does anyone at your/the clients property have a criminal history?*

Yes

No

Is there a history of drugs or alcohol misuse at the property?*

Yes

No

Do you have any pets at your premises*

Yes

No

If yes, are the pets dangerous or aggressive?*

Yes

No

Is there anything else we should know before meeting with you?*

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