Intake Form

Participant Intake Form

Please allow approximately 15 minutes to fill in this form. As our capacity to accept referrals fluctuates, its recommended that you contact us over phone or email so we can indicate our ability to consider your referral. If you need assistance filling out this form please call us on 0407 349 330 or email rebecca@careconnectco.com.au

Participant Details

First Name *

Last Name *

Gender

Date of birth *

Street Address

Suburb *

Post Code

State *

Contact Number

Email Address

Preferred method of communication

PhoneSMSEmailMail

NDIS Details

NDIS Number *

NDIS Funding Type for Support Coordination *

Self-ManagedPlan ManagedAgency ManagedNot Sure

NDIS Plan Start Date

NDIS Plan End date

Available/Remaining Funding for Support Coordination

Reason for referral *

Level 2 Support CoordinationLevel 3 Specialist Support CoordinationNot Sure

If applicable, Plan Manager/Plan Nominee details

Name

Organisation

Email

Contact Number

Personal Details

Aboriginal or Torres Strait Islander descent?

YesNo

If "other", please provide further details

Do you have a current Behavioural Support Plan?

YesNo

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 and/or Emergency Contact Details

Name

Relationship to Participant

Address

Street address

City

State

Postcode

Address

Street address

City

State

Postcode

Contact Number

Email Address

Advocacy Form Supplied?

YesNo

Advocacy Form Supplied?

YesNo

Communication

Type

VerbalNon-verbalCommunication aids requiredOther

If "other" selected, please provide further details

Languages Spoken

Is an Interpreter required?

NoYesHearing impaired

If "yes", please provide further details

Physical Health

Medications (if applicable, please list type and dose here)

I would like assistance with managing this by: (please leave blank if not applicable)

Mental Health

If "other" please provide further details here

Medications (if applicable, please list type and dose here)

History of hospital admission?

YesNo

I would like assistance with managing this by: (please leave blank if not applicable)

Dietary Requirements

If "allergies" selected, please list

Practical Support Needs

I require assistance with:

If "other" please provide further detail

If "other" please provide further detail here

The Care Connect Co can also assist me by (please leave blank if not applicable)

Your Preferences

Do you have any preferences when matching our staff with you?

Gender

MaleFemaleNo Preference

Age Group

Culture/religion/ethnicity

Languages spoken

Personality Characteristics

Specific needs, skills or knowledge required?

Specfic 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 interests and goals for the next 12 months?

Worker Safety Assessment

What is your current living situation? For example, are you living alone or with others? If relevant, who do you share your home with? *

Is the house number visible from the street? *

Do you live in an isolated area? *

Is there mobile phone coverage? *

YesNoSometimes

Does anyone at your home have a history of becoming violent or aggressive towards others? *

YesNoSometimes

If "yes" or "sometimes' selected, please provide more detail here

Do you own any animals? *

YesNo

If "yes" please describe

Does anyone smoke inside the premises? *

YesNo

Are there any weapons on the premises? *

YesNoNot sure

Finally, are you aware of anything that would be a danger to a visiting worker at your residence? *

Thank you for completing The Care Connect Co's. Intake & Referral form, we look forward to working with you. If you would like to attach a copy of your NDIS plan or any other relevant information, please do so using the link below

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