Strivesocial: Participant Intake Form
PARTICIPANT DETAILS
First Name:
Last Name:
Gender:
Date of Birth:
Address:
Suburb:
Postcode:
State:
Contact Number:
Email address:
Preferred method of communication
☐ Phone
☐ SMS
NDIS Number:
NDIS Funding Type:
☐ Self Managed
☐ Plan Managed
☐ NDIA Managed
If applicable, Plan Manager/Plan nominee details:
Name:
Organisation:
Email:
Contact Number:
Plan start date:
Plan end date:
PERSONAL DETAILS
Aboriginal or Torres Strait Islander descent?
☐ Yes
☐ No
Living Situation
☐ Own home (living alone)
☐ Own home (living with family)
☐ Living in supported accommodation
☐ Temporary (relatives, friends or other)
☐ At risk
☐ Homeless
☐ Other: ___________________________
Do you have a current Behavioural Support Plan?
☐ Yes
☐ No
Primary Formal Diagnosis:
Secondary Formal Diagnosis:
Are there any legal issues that may affect our service? If applicable, please provide details
Other relevant information:
REPRESENTATIVE OR EMERGENCY CONTACT DETAILS
CONTACT 1:
CONTACT 2:
☐ Advocate
☐ Guardian
☐ Emergency Contact
☐ Other:
☐ Parent
☐ Support Person
☐ Plan Nominee
☐ Advocate
☐ Guardian
☐ Emergency Contact
☐ Other:
☐ Parent
☐ Support Person
☐ Plan Nominee
Name:
Name:
Relationship to Client:
Relationship to Client:
Address:
Address:
Contact Number:
Contact Number:
Email:
Email:
Advocacy Form Supplied?:
☐ Yes
☐ No
Advocacy Form Supplied?:
☐ Yes
☐ No
COMMUNICATION
Type
☐ Verbal
☐ Non-Verbal
☐ Communication aids required
☐ Other: ________________________________
Languages Spoken
☐ English
☐ Other: ________________________________
Is an Interpreter required?
☐ No
☐ Language
☐ Hearing impaired
PHYSICAL HEALTH
☐ Asthma
☐ Diabetes
☐ Epilepsy
☐ Heart Conditions
☐ Visual Impairment
☐ Hearing Impairment
☐ Cognitive Impairment
☐ Blood Disorders
☐ Sleep Apnoea
☐ Other:
Medications
If applicable, please list:
I would like assistance with managing this by:
MENTAL HEALTH
☐ Depression
☐ Anxiety
☐ Post-traumatic stress disorder
☐ Bipolar
☐ Psychosis
☐ Schizophrenia
☐ Obsessive compulsive disorder
☐ Mood Disorder
☐ Other: ____________________________
Medications
If applicable, please list:
History of hospital admission?
☐ Yes (please provide further details)
☐ No
I would like assistance with managing this by:
DIETARY REQUIREMENTS
Any dietary requirements
☐ Yes
☐ No
Vegetarian
☐ Yes
☐ No
Vegan
☐ Yes
☐ No
Dairy free
☐ Yes
☐ No
Gluten free
☐ Yes
☐ No
Allergies
If applicable, please list:
I do not like to eat: (please list)
My favorite food is:
PRACTICAL SUPPORT NEEDS
I require assistance with:
Mobility
☐ Independent
☐ Walking Stick
☐ Manual Hoist
☐ Other:
☐ Assist
☐ Walking Frame
☐ Shower Chair
Personal Care
☐ Shower/Bath
☐ Grooming
☐ Other:
☐ Toileting
☐ Dressing
What Strivesocial services do you require?
In-Home and Community Supports
Daily personal Activities
Assistance with Travel/Transport Arrangements
Development of Daily Living and Life Skills
Participation in Community, Social and Civic Activities
Supported Independent Living/Respite Care/Group
Assistance with Daily Life Tasks in a Group or Shared Living Arrangement
Group and Centre Based Activities
Strivesocial can assist me by ….
YOUR PREFERENCES
Do you have specific preferences when matching our staff with you?:
Gender
☐ Male
☐ Female
☐ No preference
Age Group
Culture/Religion/Ethnicity
Languages spoken
Personality characteristics
Specific needs, skills or knowledge required?
Specific training that may be required to provide services and support to you?
Is there anything else you would like us to know about you that is important for how we provide our services to you?
What are your goals, expectations and desired outcomes when receiving our services?
What are your goals for the next 12 months?
CONSENT AND ACKNOWLEDGEMENT
By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.
Do you consent to participating in and use of:
☐ Participating in audits of our business by the NDIS Commission and its auditors
☐ Photos for Social Media
☐ Photos for our website
☐ None of the above
Signed by the Client:
………………………………………………………….. Date: ……./……./…………
Signature
…………………………………………………………..
Name (please print)
Signed by the Representative
………………………………………………………….. Date: ……./……./…………
Signature
…………………………………………………………..
Name (please print)
Signed for and on behalf of Strivesocial ABN 22 682 526 147:
………………………………………………………….. Date: ……./……./…………
Signature
…………………………………………………………..
Name (please print)