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Participant Intake Form

1. Participant Details

What services you require from us?

Short Term Accomodation (SIL)

Personal care / Support worker

Nursing services

Travel / Transport

Household task / Gardening

Community Participation

First name(Required)

Last name(Required)

Birthday(Required)

Day

Month

Year

Gender(Required)

Male

Female

Transgender

Intersex

Prefer not to say

Contact details

Mobile Phone(Required)

Email(Required)

Language spoken at home(Required)

Interpreter required(Required)

Yes

Preferred option for communication(Required)

Post

Phone

Do you identify as Aboriginal and Torres Strait Islander?(Required)

Yes

Unknown

Residential Address

Address(Required)

Is there a Guardianship and/or Administration order in place?(Required)

Yes

2. Disability / Medical Conditions

Disability / Medical Conditions including any diagnosis if relevant.

Doctor Name

Doctor Phone Number

3. Funding

Funding Source(Required)

NDIA Managed

Self Managed

Plan Managed

4. Preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communication Device

Physical Assistance

Other Considerations

5. Goals and Aspirations

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

Immediately

Immediately In 6 months

Next year

I understand that:

This form was completed by: (Provide name)(Required)

How did you hear about us?(Required)

Support Coordinator

Facebook/Google/Instagram

Family/Friend

Other

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

Records are archived for a set period according to policy and procedure

I understand that all information obtained will be kept confidential.