NDIS Services | Client Intake Assessment

client intake assessment form

The following questionnaire can be completed electronically or in person. If you are not from an English speaking background, the Australian Government provides a Translating and Interpreting Service (TIS) for people who do not speak English and for English speakers needing to communicate with them. TIS is available 24 hours a day, seven days a week. Call TIS for help with reading information written in English. Phone: 131 450.

CLIENT DETAILS

First Name *

Last Name *

Sex *

Male
Female
Other

Phone number *

Date of Birth *

Email *

Address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Indigenous background *

Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
No

Disability, Medical Condition or Health Issue Present *

If yes, please provide details

Occupation

Do you have a carer? *

If yes, please provide details

Emergency Contact

Name *

Phone *

Medicare number *

Expiry Date *

Private health Fund Name (if applicable)

Member number

NDIS DETAILS

NDIS Number

NDIS Plan Start Date

NDIS Plan End Date

Funding not to exceed

(Service Agreement total)

NDIS Billing

NDIA Managed
Self Managed
Plan Managed

I have provided a copy of my NDIS Plan

If plan managed, provide details of Plan Manager

Name

Company

Phone number

LIVING ARRANGEMENTS

Do you live alone?

Are you in a shared care arrangement?

Primary Parent / Caregiver Name(if required)

Phone

Home visits

MY PREFERENCES

Do you have any cultural, diversity, specific values or beliefs that you would like to inform us about or to centre your supports around?

We aim to sensitively respond to your needs in all aspects of service delivery. Staff are trained in cultural competence and will respect your needs appropriately.

If yes, please provide details

What kind of supports do you require?

Service start date

Service end date

Are supports

Flexible in times or days?
To be provided on Public Holidays

Days/times supports to be provided

What are your goals?

About you (NDIS participant)

CONFIDENTIALITY

We collect, store, retain, use and disclose your information to provide services to you. We may not be able to provide these services if you do not provide this information. We may use or disclose this information for:

• Administration purposes

• Billing

• Understanding your needs and wants

• Providing you with services

• Fulfilling our contract requirements to provide information to a funding or auditing body

• Duty of care purposes

• Developing further services.

DECLARATION AND DISCLOSURE OF INFORMATION

I give consent my information to be collected, stored, retained, used and disclosed for the purposes of delivering NDIS supports. I understand that this consent will remain valid until the expiry of our current NDIS/Service plan. I am aware that I can access my information on request and if necessary, correct information that I believe to be inaccurate. I understand that my information can be shared under the Information Sharing Guidelines for Promoting Safety and Wellbeing without my consent, provided:

• It is unreasonable or impracticable to seek consent; or consent has been refused; and

• The disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people.

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