Participant Intakeform

Participant Intake Form

1. Participant Details
Participant Name
D.O.B
Date Format: MM slash DD slash YYYY
Gender
Contact Details : Home
Mobile
Email
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:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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

Parent / Guardian 1
Name of Parent/Guardian 1
Primary Carer
- Yes
- No
Lives with Participant
- Yes
- No
Emergency Contact
- Yes
- No
Relationship to participant
- Parent
- Guardian
- Caregiver
- Other
Residential Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Details : Home
Mobile
Email
Parent / Guardian 2
Name of Parent/Guardian 2
Primary Carer
- Yes
- No
Lives with Participant
- Yes
- No
Emergency Contact
- Yes
- No
Relationship to participant
- Parent
- Guardian
- Caregiver
- Other
Residential Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Details : Home
Mobile
Email
2.Disability / Medical Conditions including any diagnosis if relevant.
2.1. Other service providers currently using
Name
Address
Phone number/email
Frequency of use:
3.Health Care Information
Medicare Number
Expiry Date:
Date Format: MM slash DD slash YYYY
Reference Number:
Private Healthcare Provider
Membership Number
Reference Number:
Doctor Name
Address
Phone Number
4. Funding
- NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)
NDIS Number
NDIS Date
Date Format: MM slash DD slash YYYY
- Self-Managed
- Plan Managed
Name
Email
Comments
5. Preferences
Preferred name
Religious Requirements
Cultural Requirements
Communication device
Physical Assistance
Other Considerations
6. Goals and Aspirations
What do you want to achieve for yourself – life skills, physically, socially etc?
Immediately
In 6 months
Next year
I understand that:
- 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:
Signature of Participant or Parent/Caregiver:
Relationship to participant:
Name
Date
Date Format: MM slash DD slash YYYY