Participant Intake Form
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Intake Details
Date of Intake
Referred By
Participant Personal Details
First Name
Last Name
Male
Female
Non-Binary
Prefer not to say
Aboriginal / Torres Strait Islander
Preferred Name
Culture Origin
Language Spoken
Date of Birth
Residential Address
Number / Street
State
Postcode
Postal Address
Number / Street
State
Postcode
Contact
Email
Home Phone
Mobile Phone
Primary Care Person
First Name
Last Name
Address
Suburb & Postcode
Email
Mobile
Relationship
Emergency Contact
First Name
Last Name
Address
Suburb & Postcode
Email
Mobile
Relationship
NDIS Information & Funding
NDIS Number
Plan Review Date
NDIS Start Date
NDIS End Date
Plan Managed
Self-Managed
NDIA Managed
Other
If Plan Managed, details
Support Coordinator
Name
Mobile
Organisation
Phone
Email
NDIS Plan
*Optional
Registered with another provider – Yes
Registered with another provider – No
Medical History
Primary Disability (tick one)
Acquired Brain Injury
Autism Spectrum Disorder
Cerebral Palsy
Deafblind (Dual Sensory)
Dementia
Developmental Delay
Down Syndrome
Genetic/Chromosomal Disorder
Hearing Impaired
Intellectual
Mental Health
Neurological (incl. Epilepsy, Alzheimer’s)
Psychiatric
Physical
Speech
Vision Impaired
Primary Disability Details
Secondary Disability (tick any)
Autism Spectrum Disorder
Cerebral Palsy
Deafblind (Dual Sensory)
Dementia
Developmental Delay
Down Syndrome
Hearing Impaired
Intellectual
Mental Health
Neurological (incl. Epilepsy, Alzheimer’s)
Psychiatric
Physical
Speech
Vision Impaired
Secondary Disability Details
Additional Information
Behaviours of concern?
No
Yes
Behaviour Support Plan Details
Communication support required?
No
Yes
Communication Plan / Contacts
Meal / swallowing support required?
No
Yes
Meal Support Details
Health condition?
No
Yes
Health Condition Details
Medication support required?
No
Yes
Medication Schedule (up to 5 items)
Medication
Dosage
Route
Day
Time
Frequency
Support Requirements
Community Access
Assistance with Personal Care
Assistance with Daily Living Skills
Meal Preparation
Sleepover Care
Housekeeping
Any others (specify)
Requires Registered/Enrolled Nurse – Yes
Requires Registered/Enrolled Nurse – No
Documentation Requirements
Care Plan
Behaviour Chart
Medication Chart
PEG Chart
Progress/Shift Notes
Sleep Diary
Meal & Liquids Chart
Bowel Movement Chart
Turn & Reposition Chart
Mood Chart
Any others (specify)
Hours & Days of Support
Day
Morning
Afternoon
Evening
Night
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Support Worker Preferences & Transport
Support Worker Preferences
Expectations from Support Workers
Transport required – Yes
Transport required – No
Special Transport Requirements
Additional Notes
Intake Officer (Unique Needs Staff to complete)
Name
Position
Date
Signature (type name)
Date of Next Review
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