Intake form

1. Participant Details

Participant Name

First Middle Last

D.O.B

Gender

Home Phone

Mobile Phone

Email Address

Language spoken at home

Interpreter required

Yes
No

Preferred option for communication

Email
Post
Phone

Do you identify as Aboriginal and Torres Strait Islander?

Yes
No

Residential Address

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

Postal Address (If different from above)

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

Is there a Guardianship and/or Administration order 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

Lives with Participant

Yes
No

Emergency Contact

Yes
No

Relationship to participant

Parent
Guardian
Caregiver
Other

Residential Address

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

Postal Address (If different from above)

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

Home Phone

Mobile Phone

Email Address

Name of Parent/Guardian 2

Primary Carer

Yes
No

Lives with Participant

Yes
No

Emergency Contact

Yes
No

Residential Address

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

Relationship to participant

Parent
Guardian
Caregiver
Other

Postal Address (If different from above)

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

Home Phone

Mobile Phone

Email Address

2. Disability / Medical Conditions including any diagnosis if relevant.

Other service providers currently using

Name

First Middle Last

Address

Phone Number/Email

Frequency of Use

Name

First Middle Last

Address

Phone Number/Email

Frequency of Use

Name

First Middle Last

Address

Phone Number/Email

Frequency of Use

3. Health Care Information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

Doctor's Name

First Last

Address

Phone Number

4. Funding

NDIS

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

NDIS Number

NDIS Date

NDIS Plan Dates

Transport (KM)

Transport Invoiced

Total Amount Allocated

What hours and days do you want for support shifts

Managed

Self Managed
Plan Managed

Name

First Middle Last

Email

Comments

5. Preferences

Preferred Name

First Middle Last

Religious Requirements

Cultural requirements

Communication Device

Physical Assistance

Other Considerations

6. Goals and Aspirations

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

Immediately

In 6 Months

Next Year

Consent

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

I understand that:
1) These records are owned by this organisation.
2) 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
3) I can ask to see records and receive a copy
4) Records are archived for a set period according to policy and procedure
5) I understand that all information obtained will be kept confidential.

Name

First Middle Last

Date

Relationship to participant

How did you hear about Including You

Website
Professional Referral
Word of mouth

CAPTCHA

Participant Intake

1. Participant Details

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below

Other service providers currently using

3. Health Care Information

4. Funding

5. Preferences

6. Goals and Aspirations