NDIS Participant Intake Form
Does the participant have a Support Coordinator
*
Yes
No
Support Coordinator Name
Organisation
Phone
Email Address
About The Client
First Name
*
Last Name
*
Date of Birth
Preferred Name
Gender
*
Male
Female
Unspecified
Phone Number
*
Address
Suburb
Postal address is the same
Postal Address
Email Address
*
Preferred option for communication
Phone
SMS
Email
Post
Cultural Background
Aboriginal or Torres Strait Islander?
Aboriginal
Torres Strait Islander
Neither
Languages spoken at home
Interpreter required?
*
Yes
No
Representative Details
Role
I am the Client
Parent
Legal Guardian
Caregiver
Support Coordinator
Authority to make decisions for participant?
*
Yes
No
Do you live with the participant?
Yes
No
Full Name
Phone Number
Email Address
Address
Suburb
Postal address is the same
Postal Address
Preferred option for communication
Phone
SMS
Email
Post
Funding Information
NDIS Number
Plan Start Date
Plan Finish Date
Plan Management Type
*
NDIS Managed
Plan Managed
Self Managed
Plan Manager Name
Organisation
Phone Number
Email Address
Emergency Contact Details
Emergency Contact Name
Emergency Contact Phone
Participant Medical Information
Allergies/Dietary Requirements
Medication Required
*
Yes
No
Assistance with Medication Required
*
Yes
No
Medication Review in the Last 6 Months?
*
Yes
No
Medication Details
GP Name
GP Practice Name
GP Address
GP Phone Number
GP Email Address
Epilepsy or Asthma
Epilepsy
Asthma
Please provide details
Support Needs
Category of Disability
Physical
Psychosocial
Intellectual
Sensory
Neurological
Cognitive
Hearing
Visual
Disabilities/Diagnosis
Physical Assistance or Equipment Required?
Yes
No
Physical Assistance Details
Uses assistive technology?
Yes
No
Assistive Technology Details
Uses assistive communication devices?
Yes
No
Assistive Communication Device Details
Visually Impaired?
Yes
No
Visual Impairment Details
Swallowing Difficulties?
Yes
No
Swallowing Difficulty Details
Mealtime Management Plan Available?
Yes
No
Other Support Plans?
Yes
No
Other Support Plan Details
Behaviours of Concern?
Yes
No
List behaviours of concern
Behaviour Support Practitioner Attached?
Yes
No
Behaviour Support Practitioner Name
Behaviour Support Practitioner Organisation
Behaviour Support Practitioner Phone
Behaviour Support Practitioner Email
Behaviour Support Plan available for review?
*
Yes
No
Religious/cultural requirements
Likes/preferences
Dislikes/Phobias
General safety issues
Road safety
Stranger Danger
Water safety
Falls
Uncontrolled movements
Wandering without supervision
Other
Toileting support level
No
Verbal Prompting/Supervision
Full Assistance
Showering Support Level
No
Verbal Prompting/Supervision
Full Assistance
Allied health involved?
Yes
No
Allied health details
Supports Required
Daily Living Supports
Assistance with Self-Care (SC)
Capacity Building (CB)
Community & Social Participation
Access Community (AC)
Day Program/s (DP)
Group Activities (GR)
Community Hub Drop-in
Accommodation Supports
Short Term Accommodation (STA)
Medium Term Accommodation (MTA)
Support Independent Living (SIL)
Independent Living Options (ILO)
Coordination & Employment
Support Coordination (SCo)
Assist and Maintain Employment (ME)
Support on Public Holidays?
Yes
No
Monday Support
Yes
No
Monday AM Time (Start - End)
Monday PM Time (Start - End)
Monday Notes
Tuesday Support
Yes
No
Tuesday AM Time (Start - End)
Tuesday PM Time (Start - End)
Tuesday Notes
Wednesday Support
Yes
No
Wednesday AM Time (Start - End)
Wednesday PM Time (Start - End)
Wednesday Notes
Thursday Support
Yes
No
Thursday AM Time (Start - End)
Thursday PM Time (Start - End)
Thursday Notes
Friday Support
Yes
No
Friday AM Time (Start - End)
Friday PM Time (Start - End)
Friday Notes
Saturday Support
Yes
No
Saturday AM Time (Start - End)
Saturday PM Time (Start - End)
Saturday Notes
Sunday Support
Yes
No
Sunday AM Time (Start - End)
Sunday PM Time (Start - End)
Sunday Notes
Participant Goals
Short term goal #1
Short term goal #2
Long term goal #1
Long term goal #2
Consents
Information Sharing & Media
Yes
No
Water Activities
Yes
No
Audit Participation
Yes
No
Restrictive Practices
Yes
No
Medication Administration
Yes
No
Name (Participant or Authorised Representative)
Signature
Draw signature
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Type signature
Clear
Date
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