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Participant Intake Form
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Participant Details
First Name
(Required)
Last Name
Date of Birth (D.O.B)
(Required)
Gender
Male
Female
Cultural background:
Address
Different postal address?
Yes
No
Postal Address
Mobile
Phone
Email
Language Spoken at Home
Interpreter Required
Yes
No
Do you identify as Aboriginal and Torres Strait Islander?
Yes
No
Preferred Option for Communication
Email
Phone
Post
Select All
NDIS Funding Type
NDIS Managed
Self-Managed
Plan Managed
Upload NDIS Plan
Max. file size: 128 MB.
NDIS Number
NDIS Start Date
NDIS End Date
Invoicing Details
First Name
Last Name
Preferred Option for Communication
Phone
Email
Address
Does the participant have a representative?
(Required)
Yes
No
Representative Details
Name of Representative
Lives with Participant?
Yes
No
Relationship to Participant
Parent
Guardian
Caregiver
Others
Others, Please Specify
Address
Phone
Email
Preferred Option for Communication
Emergency Contact Details
Is emergency contact the same as above?
(Required)
Yes
No
Emergency Contact Name
Lives with Participant?
Yes
No
Relationship to Participant
Parent
Guardian
Caregiver
Others
Others, Please Specify
Address
Phone
Email
Preferred Option for Communication
Health Care Information
Medicare Number
Medicare Expiry Date
Reference Number
Private Health Provider
Membership Number
Reference Number
About the Participant
Living situation
Living alone in my own home
Living with my family
Supported Accommodation
Temporary
Others
Others, please specify
Types of disability
Religious / cultural requirements
Does the participant need physical assistance equipment or support?
Yes
No
Does the participant need assistive devices for communication?
Yes
No
Is the participant visually impaired?
Yes
No
Does the participant have any dietary requirements
Yes
No
Does the participant have any swallowing difficulties?
Yes
No
Does the participant have a current behavioral support plan?
Yes
No
If yes, please provide the details of your behavior practitioner
Practitioner’s name:
Practitioner’s Contact number:
Practitioner’s Address
Other considerations
Medical Information
Medical condition / diagnosis
Allergies
Please provide details of your medical practitioner
Name
Phone
Address
Current Service Providers
1. Name
Address
Phone
Email
Emegerncy Contact Number
Frequency of Use
Type of service
2. Name
Address
Phone
Email
Emegerncy Contact Number
Frequency of Use
Type of service
3. Name
Address
Phone
Email
Emegerncy Contact Number
Frequency of Use
Type of service
4. Name
Address
Phone
Email
Emegerncy Contact Number
Frequency of Use
Type of service
Goals
What do you want to achieve for yourself – life skills, physical, social etc?
Short-term goals
Long-term goals
Consent
Please sign below to show that you agree with the information in this client intake form.
(Required)
I consent to the information provided in this Participant Intake Form being used by NBS Health Services for the purposes of assessment, service delivery, and required reporting.
Who is completing this form?
(Required)
Participant
Parent / Caregiver
Participant Signature
Type full name as signature
Parent / Caregiver Signature
Type full name as signature
Name of person signing
(Required)
Relationship to participant
(Required)
Parent
Guardian
Caregiver
Other
Others, please specify
Date