Client Intake Form

Participant Title Participant First Name Participant Last Name Gender Select GenderMaleFemaleIndeterminate/Intersex/Unspecified Date of Birth Street Number & Name Suburb Post Code

Is the Postal Address the same as the Residential Address? YesNo Country of Birth Nationality Language Spoken Emergency Contact Name Do you have a Medicare Number? YesNo Do you have Ambulance Cover? YesNo Do you have a Pensioner CRN Number? YesNo Do you have GP Details? YesNo Do you have Pharmacy Details? YesNo

Relationship to Participant Contact Number Email Address Address of Emergency Contact Guardian Name & Contact Details Do you have an NDIS Registration Number? YesNo Do you have an NDIS Plan Manager? YesNo Do you have a Plan Manager Contact? YesNo

NDIS Planner Contact Details Do you have an NDIS Planner Email? YesNo Does the participant have a Support Coordinator? YesNo Support Coordinator Contact Do you have a copy of your NDIS Plan? YesNo Services Requested Support Ratio Required Total Days Spent in Care in the last 12 months Current Support Provider

Do you have Allied Health / Treating Professionals? YesNo Medication Summary

Do you have Allied Health Details? YesNo Allied Health Details Do you have Treating Specialist Details? YesNo Primary Disability Secondary Disability Health Summary

Behaviours of Concern Behaviours of Concern Summary Positive Behaviour Support Plan Cognitive Function Summary Reports Participant’s Support PlanRisk AssessmentSACAT OrderOccupational Therapy Report/FCA ReportBehaviour Support Plan/PBSB/CBSPGP Management Plan / CHAPHealth Support PlanMealtime Management Plan / Dietetic PlanCPAP Care PlanColostomy Care PlanManual Handling PlanDiabetes Management PlanCatheter Care PlanEpilepsy Management PlanNot applicable Upload Document

Mobility Needs Mobility Summary Continence Continence Management Continence Summary Nutrition/Diet Dietary Preferences

Allergies Allergy Details Additional Support Plans Communication Needs Communication Summary Staff Preference

Cultural Considerations Family Engagement Financial Engagement Decision Making Responsibility Other Needs/Preferences

Personal Care Needs Personal Care Routine Meal Time Management Routine Medication Administration NDIS Goals Personal Development Goals

AM/PM Routine Activities of Daily Living Likes Dislikes Community Participation Community & Secondary Supports