PARTICIPANT INTAKE FORM

PARTICIPANT INTAKE FORM

  • Participant Details
  • Disability / Medical
  • Health Care Information
  • Funding
  • Preferences
  • Goals and Aspirations
  • I understand

Participant Details

Contact details

  
     

  

  

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers please complete below

  

  
  
     


DISABILITY / MEDICAL

Other service providers currently using




HEALTH CARE INFORMATION

Funding

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

     

PREFERENCES

GOALS AND ASPIRATIONS

I understand that:

▪ These records are owned by this organisation.


▪ Information within these records will be shared with other staff within the organisation on and

only when staff require the information to carry out their duties


▪ I can ask to see records and receive a copy


▪ Records are archived for a set period according to policy and procedure


▪ I understand that all information obtained will be kept confidential.



To the best of my knowledge, the information provided in this form is true and correct:



I agree