Intake Form

Participant Details

Name of Person interviewed to complete this form: *

Relationship/title: *

Preferred Contact Details *

Name of Participant *

Preferred Name:

Date of Birth *

Gender

Female Male Intersex or Indeterminate

Address: *

Street address *

City *

State

Postcode

Email Address:

Contact Number:

Preferred Language/dialect: *

Interpreter required? *

YesNo

NDIS Number: *

NDIS Plan Dates: *

Please Provide NDIS Goals *

Specify Hours

Funding Type

Funding type *

Plan Managed Agency Managed Self-Managed

Able to choose multiple.

If Plan Managed or Self-Managed - Name:

Email address for invoicing: *

Primary carer/ Next of kin/ Advocate/ Guardian details

Full name: *

Relationship to person: *

Best contact number: *

Best Email Address: *

About Me

Physical Profile

Weight (kg)

Height (cm)

Facial Hair

YesNo Prefer not to say/Unknown

Birth marks

Yes No Prefer not to say/Unknown

Tattoos

Yes No Prefer not to say/Unknown

Culture, Communication & Intimacy:

Are there any cultural, communication barriers or intimacy issues that need to be considered when delivering services? *

YesNo

If Yes, specify

Cultural values/ beliefs or assumptions: *

Cultural behaviours:

Written communication/literacy:

Living and support arrangements

What is the current living arrangement? *

If Other, please specify

Transition Plan, i.e., transitioning from home/hospital or another facility into Community Support/SIL? *

YesNo

If yes, a Transition Plan will need to be completed in addition to this form.

Travel

How does the individual travel to work or to their day service? *

Taxi Pick up/ drop off by Parent/Family/Support PersonTransport provided by a provide Independently use Public Transport Walk Assisted Public Transport Drive own car Other

If other, please specify:

Disability Conditions/Disability type(s)

Indicate what type of disability or disabilities the individual have? *

What are their likes/strengths: *

What are their dislikes/ challenges: *

What might trigger them/ make them anxious?

Support Worker preference

Any preference for the Support workers’ gender? *

Male Female NIL preference

What are important qualities in a support worker and what don’t they like? *

Medication Information/Health Concerns

Does the individual take any regular medication? *

Yes NoUnknown

If yes, please provide a patient health summary

Do they require support with administering medication? *

Yes No

If yes, SNL will request for a Medication Chart to be completed with your GP/doctor.

If other, please specify below:

If any of the above are ticked, please let us know if any of the following are available:If available, SNL will request a copy of it.

If other please specify below:

Does the individual have any allergies? *

Please specify warning signs/symptoms and immediate actions are required:

Any regular appointments with allied health or medical practitioners that we should be aware of? *

Safety Considerations

Is the individual prone to falls or have history of falls? *

Yes No Unknown

Does the participant require any physical assistance i.e., transfers *

Yes No Unknown

Are there any signs, or a history of, respiratory depression? *

Yes No Unknown

Weekly schedule of activities/routine

Monday (Activity, Start - Finish, any details)

Tuesday (Activity, Start - Finish, any details)

Wednesday (Activity, Start - Finish, any details)

Thursday (Activity, Start - Finish, any details)

Friday (Activity, Start - Finish, any details)

Saturday (Activity, Start - Finish, any details)

Sunday (Activity, Start - Finish, any details)

Signature of person completing this form. *

Draw signature|Type signatureClear

Date: *