Participant Intake Form

Form20. Participant Intake Form

Part 1Step 1 of 3

Version No: 01

Version Date: 01/08/2023

Date

Participant Details:

Given Name:

Surname:

Do you have a preferred gender and/or pronoun?

Male
Female
Intersex or Indeterminate
Do not wish to disclose
Other – provide details below

Preferred gender:

Preferred pronoun:

Are you an Aboriginal or Torres Strait Island descent?

Preferred name:

Date of Birth:

Residential Address Details:

Address Line 1

City

State / Province / Region

Zip / Postal Code

Postal Address Details:

Address Line 1

City

State / Province / Region

Zip / Postal Code

Participant Contact Details:

Home Phone No:

Mobile No:

NDIS Information:

NDIS Number:

Plan review date (Must be reviewed annually):

NDIS Start Date:

NDIS End Date:

Funding Type:

Plan Managed (If selected fill in the below details)
Self-Managed
NDIA Managed
Other

Provider Name:

Email Address:

Contact Number:

Other NDIS Providers:

Are you registered with another NDIS provider?

If yes, please specify the service you are receiving with the NDIS provider:

Advocate/representative details (if applicable):

Surname:

Given name(s):

Relationship with the participant:

Phone

Mobile No

Address

Address Line 1

City

State / Province / Region

Zip / Postal Code

Postal Address Details:

Address Line 1

City

State / Province / Region

Zip / Postal Code

Other Information:

Country of Birth:

Country

Number of years in Australia (if not born in Australia):

The main language spoken at home:

Culture, Communication & Intimacy:

Are there any cultural, communication barriers or intimacy issues that need to be considered when delivering services?

Verbal communication or spoken language - Is an interpreter needed?

Specify Language

Cultural values/ beliefs or assumptions:

Cultural behaviours:

Written communication/literacy:

Physical Profile

Weight:

KGs (Kilograms)

Height:

CMs (centimetres)

Eye Colour:

Brown
Hazel
Green
Blue

What is your build?

Small
Medium
Large

Facial Hair?

Birth Marks?

Tattoos?

What is your complexion?

Fair
Light
Olive
Dark

Hair Colour:

Brown
Blonde
Red
Black
Grey
Bold

Emergency Details (Primary Contact)

Contact Name:

Relationship

Home Phone No:

Mobile No:

GP Medical Contact

Clinic Name:

Email Address:

Surname

First Name

Address

Address Line 1

City

State / Province / Region

Zip / Postal Code

Telephone Number:

Mobile Phone Number:

Support Coordination Details:

Contact Name:

Relationship

Phone No:

Specialist Medical Contact/Behaviour Support Practitioner (if applicable)

Do you see a specialist for a medical condition/disability?

Clinic Name:

Surname

First Name

Address

Address Line 1

City

State / Province / Region

Zip / Postal Code

Telephone Number:

Mobile Phone Number:

Living and support arrangements

What is your current living arrangement? (Please tick the appropriate box)

Live with Parent/Family/Support Person
Live in private rental arrangement with others
Live in private rental arrangement alone
Aged Care Facility
Mental Health Facility
Short Term Crisis/Respite
Hostel/SRS Private Accommodation
Owns own home
Lives in public housing
Staff Supported Group Home
Other, please specify

Travel

How do you travel to work or to your day service? (Please tick the appropriate box)

Taxi
Transport provided by a provide
Walk
Drive own car
Pick up/ drop off by Parent/Family/Support Person
Independently use Public Transport
Assisted Public Transport
Other

if you choose Other, please specify

Disability Conditions/Disability type(s)

Indicate what type of disability or disabilities this participant has including diagnosis eg: ADHD

Are there any important people in the Participant’s life such as family member and their relationship?

Medication Information/Diagnosis/Health Concerns

Does the Participant require a Medication Chart?

If yes, is this medication taken on a regular basis and for what purpose, ensure to make mention of this here and complete Form40.Medication Chart and/or Form33. Participant risk assessment

Does the Participant require Mealtime Management?

If yes, refer to Form77. Mealtime Management Plan Form

Does the participant require Bowl Care Management?

If yes, refer to Form49. Complex Bowel Care Plan and Monitoring Form and indicate what assistance is required with bowel care

Is there any issues with a menstrual cycle or is assistance needed?

If yes, please specify:

Does the Participant require female hygiene assistance?

Does the Participant have Epilepsy?

If yes, ensure Participant’s Doctor completes an Epilepsy Plan

Is the Participant an Asthmatic?

If yes, ensure Participant’s Doctor completes an Asthma Plan

Does the Participant have any allergies?

If yes, ensure to have an Allergy Plan from Participant’s Doctor

Is the Participant anaphylactic?

If yes, ensure to have an anaphylaxis Plan from the Participant’s Doctor

Do you give permission for our company’s staff to administer band-aids in cases of a minor injury?

Does this participant require specific training?

If yes, ensure to provide information such as implementing a positive behaviour support plan

Are there any other medication conditions that will be relevant to the care provided to this Participant?

If yes, please specify

IS there any specific trigger for community activities?

If yes, please specify and complete the Risk assessment for participants in Form27.Initial Assessment and Support Plan

Safety Considerations

Does the Participant show signs or a history of unexpectedly leaving (absconding)?

If yes, please specify

Does the Participant show any signs or a history of respiratory depression?

If yes, please specify the type of medication that was prescribed.

Is this participant prone to falls or have a history of falls?

Is there any behaviours of concern? Eg: kicking, biting.

If yes, please specify

Is there a current Positive Behaviour Support Plan (PBS) in place?

If yes, refer to Form56.High Risk Participant Register.

Does the participant require communication assistance?

If yes, refer to the mode of communication reflected in Form33. Participant Risk Assessment and disaster management plan

Is there any physical assistance or physical assistance preference for this Participant?

If yes, please specify

Does the Participant have any expressive language concerns?

If yes, Form33. Participant Risk Assessment and disaster management plan under OH&S Assessments and Mode of Communication.

Does this Participant have any personal preferences & personal goals?

If yes, refer to form Form27.Initial Assessment and Support Plan

OHS & risk assessments

Refer to Form33. Participant Risk Assessment and Disaster Management Plan

Signature of participant:

Press X to clear the signature

Date

[If signed by a Nominee:]
I confirm that this agreement has been explained to the person receiving the services (participant) and that they agree to this:

Signature of Nominee:

Press X to clear the signature

Date

Signature on behalf of [Organisation Name]

Press X to clear the signature

Date

Name