DETAILED PARTICIPANT INTAKE FORM

Detailed Participant Intake

Part 1: Participant Details

Participant Contact Information

Participant Address

Participant Education / School (if applicable)

NDIS Plan

Financial Management Arrangements

Health Information

GP Details

Chemist Details

Part 2: Representative Details (if applicable)

Decision-Making Support Person 1 Details

Decision-Making Support Person 2 Details

Days and Times Support is Requested

Part 3: Disability Support Information

Disability Needs

Mobility

Hearing

Vision

Memory / Cognition

Communication

Continence

Aids and Equipment

Aid / Equipment 1 Used

Aid / Equipment 2 Used

Aid / Equipment 3 Used

Daily Living

Showering / Bathing

Grooming

Dressing

Toileting

Eating

Transfers (e.g. in and out of bed)

Day and Night Support

Part 4: Health Support Needs

Health Issues

Part 5: Behaviour Support Needs

Part 6: Community Support Needs

Part 7: Privacy Statement and Declaration

Your personal information is protected by law (including the Privacy Act 1988) and is collected by Client Care First in order to assess and administer its disability support services. Your information may be used by Client Care First or given to other parties where you have agreed to that, or where it is required or authorised by law. More information about how we manage your privacy is contained in our Privacy Statement, which can be provided by Client Care First.

I have been informed and consent to the use of my information in the assessment and administration of my services. I understand that this information may be provided to external agencies where I have consented to this, or where it is required by law.


I declare that all of the information I have provided in this form is, to my knowledge, true and correct.

Staff Use Only


Verbal consent should only be used where it is not practicable to obtain written consent.


I have discussed this form and its content with the participant or authorised representative, and I am satisfied that they understand the proposed uses and disclosures of their information and have provided their informed consent to these.