Participant Referral and Pre-Intake Form

Particiapant Information

First name *

Middle name

Surname *

Date of birth *

Gender

MaleFemaleOther

Identifies as

Do you (the participant) identify as Aboriginal or Torres Straight Islander?

YesNo

Language spoken at home

Participant Contact Details

Email Address *

Mobile phone *

Home *

Street address *

City *

State *

Postcode *

Do you have a different postal adress? *

YesNo

Postal address

PO Box

City

State

Postcode

Is the participant under the age of 18, under guardianship or in the care of family or caregivers? *

YesNo

Parent/Gaurdian full name

Relationship to participant

ParentGaurdianCaregiverOther

Are they the participant's primary carer?

YesNo

Does the participant live with them?

YesNo

Parent/Gaurdian's mobile phone number

Parent/Gaurdian's address

Street address

City

State

Postcode

Emergency Contact Information

Emergency contact name *

Emergency contact mobile phone *

Emergency contact’s relationship to you *

Health & Support Information

Is there a Behaviour Support Plan in place? *

YesNo

Does the Behavior Support Plan include restrictive practices? *

YesNo

Is the participant currently taking any medication? *

YesNo

Please specify

Is the medication self administered? *

Yes NoRequires PromptingOther

Please Specify *

Does the participant have any allergies? *

Yes No

Please specify

Disability / Medical Conditions including any relevant diagnosis

Is the participant currently using any other service providers

YesNo

Additional service providers

Physical aggression - towards others, which can include hitting, biting, spitting or kicking.

Verbal aggression - towards others includes shouting, making threats or calling names.

Self Injury - actions where the individual causes harm to themselves, such as head-banging, cutting or self-biting

Non Compliance - refusing to follow rules or instructions, which can disrupt activities or routines.

Withdrawal or Isolation - avoiding interaction with others, not participating in group activities, or showing signs of social disengagement

Inappropriate Social Behaviour - acting in ways that are socially unacceptable or inappropriate for the context, such as undressing in public or using offensive language

Sexualised Behaviour - non-consensual touch, sexually explicit language or exposing one's genitals in inappropriate settings

About You (participant) - optional

Preferred name

Cultural requirements

Religious requirements

Anything else you would like us to know?

Referral Information

Referral Type *

Group Activities In The CommunityAccess Community Social And Rec ActivitiesAssistance With Self Care Activities

NDIS Immediate Goals *

NDIS Short Term Goals *

NDIS Long Term Goals *

Information about me (My profile - NDIS Plan profile page) - optional

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Plan Details

NDIS Number *

NDIS Plan expiry date *

Upload NDIS Plan - optional

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Support Preferences

Total Weekly Hours of Support Required (approximate)

Day

Time

Duration

Budgeted Weekly Spend

Plan Management

The Participant's Plan is *

Plan ManagedSelf Managed

Plan manager *

Email invoices to *

Plan manager's contact name

Plan manager's contact number

Billing contact name *

Billing contact number *

Email invoices to *

Consent

I confirm that above information I have provided is true, complete and accurate. *

I am the participant *

YesNo

I have the authority to sign on behalf of the participant *

Yes

Relationship to the participant *

Full name *

Email *

Signature *

Draw signature|Type signatureClear

Date *