NDIS Participant Intake Form

Participant’s Name

Address of Participant

Participant’s Date of Birth

Participant’s contact details

Preferred contact method

Preferred contact person

Name of person registering client for NDIS services.

(Please confirm if person registering client for services is able to sign on participant’s behalf and if yes, request signed documentation)

Relationship to participant:

Participants Plan Nominee contact details or contact person.

Relationship to participant:

Does the participant give consent for our service to contact the plan nominee?

Yes

Interpreter required?

Yes

Participant’s primary disability?

Other medical conditions (if any)

Do you identify as Aboriginal or Torres Strait Islander?

Yes

Are there any cultural considerations that we need to know about? (please specify)

Participant’s occupation

Does the Participant access a Centrelink benefit? If so, what benefit?

NDIS Details

Participant’s NDIS Number

NDIS Plan dates

Can you please send through a copy of the participants NDIS plan?

Yes

Has the participants NDIS portalbeen set up

Yes

For Therapy/Support Coordination, is the Participant’s Plan self- managed, NDIA or Plan Managed?

Referral Information

What NDIS funded service/s are you requesting through Aramaic Care?

Reason for referral

Current services being received by the participant eg. OT, Physio. Speech therapist, AOD ( Alcohol and or Other Drug), Other – please specify

Contact details of organisations providing current services to Participant

Is there any issues that we need to know that might result in risk to staff or the participant? (e.g Any special family circumstances or legal orders in place, behaviours of concern, drug and alcohol issues)

Contact details and signature of worker completing this form

Name

Position

Contact details

Signature of worker

Date

Online Intake Form

Participants Information

Participant’s contact details

Name of person registering client for NDIS services.

Participants Plan Nominee contact details or contact person.

NDIS Details

Referral Information