Participant Intake Old

Participant Details

Participant Name

D.O.B

Gender

Male Female

Contact details

Home

Mobile

Email address

Language spoken at home

Interpreter required

Yes No

Preferred option for communication

Email

Post

Phone

Do you identify as Aboriginal and Torres Strait Islander?

Yes No

Residential Address

Postal Address (If different from above)

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

Yes No

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below

Primary Carer

Yes No

Name of Parent/Guardian

Lives with Participant

Yes No

Emergency Contact

Yes No

Relationship to participant

Parent

Guardian

Caregiver

Other

Residential Address

Postal Address (if different from above)

Home

Mobile

Email address

Disability / Medical

Disability / Medical Conditions including any diagnosis if relevant.

Other service providers currently using

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Health Care Information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

Doctor Name

Phone Number

Address

Funding

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

NDIS Number

NDIS Date

Managed

Self-Managed

Plan Managed

Name

Email

Comments

Preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communication device

Physical Assistance

Other Considerations

Goals And Aspirations

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

Immediately

In 6 months

Next year

I understand

These records are owned by this organisation.
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
I can ask to see records and receive a copy
Records are archived for a set period according to policy and procedure
I understand that all information obtained will be kept confidential.
To the best of my knowledge, the information provided in this form is true and correct:

Participant Intake Old

Participant Details

Participant Name

D.O.B

Gender

Contact details

Home

Mobile

Email address

Language spoken at home

Interpreter required

Preferred option for communication

Do you identify as Aboriginal and Torres Strait Islander?

Residential Address

Postal Address (If different from above)

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

Primary Carer

Name of Parent/Guardian

Lives with Participant

Emergency Contact

Relationship to participant

Residential Address

Postal Address (if different from above)

Home

Mobile

Email address

Disability / Medical

Disability / Medical Conditions including any diagnosis if relevant.

Other service providers currently using

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Health Care Information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

Doctor Name

Phone Number

Address

Funding

NDIS Number

NDIS Date

Managed

Name

Email

Comments

Preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communication device

Physical Assistance

Other Considerations

Goals And Aspirations

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

Immediately

In 6 months

Next year

I understand

I agree