Participant Intake Referral Type: Seeking Support WorkerSeeking Support Coordination Client Information Full Name* Diagnosis* Date of Birth* Sex* MaleFemaleOther Nationality Indigenous status YesNo Address Post Code Home Phone Mobile Email Living Arrangement With ParentsPrivate RentalAged/Nursing HomeSupported AccommodationOther (Please specify:) Preferred Language Interpreter Required YesNo Next of Kin / Guardian Details Full Name Relationship Email Address Post Code Home Phone Mobile NDIS Plan Information NDIS Fund Management Self-ManagedNDIS ManagedPlan Managed NDIS Reference Number NDIS Service Plan Start Date NDIS Review Date Payment/Invoicing Details Portal Service Bookings required? YesNo Organisation Phone Email Fax Support Co-Ordinator Details Coordinator Name Organisation Contact Number Email Address Client Health Information Disability and Health Primary Disability Secondary Disability Other Health Alerts Medical Condition Allergies Does the client have regular medications? YesNo Is the client able to self-medicate? YesNo Personal care Requires support with toileting YesNo Able to self-dress and groom YesNo Requires support with showering/bathing YesNo Communication The client is Fully VerbalNon-VerbalOther Comments or other considerations Mobility The client is IndependentNon-AmbulantRequires some supervision Other Mobility Considerations About the Participant About Me Likes Dislikes Goals Short-term Medium-term Long-term Behavioural Information Are there behaviours of concern? YesNo If yes, please provide a brief description, or a behavioural management plan Behavioural Information Please select when support is required. Monday AMPM Tuesday AMPM Wednesday AMPM Thusrday AMPM Friday AMPM Saturday AMPM Sunday AMPM Total Cost NDIS Hours Approved NDIS Support Category Staff Gender Preference MaleFemaleNo Preference Further Information Please list any other information or any circumstances that we need to be aware of
