Intake Form

Participant Referral Details

Participant Name *

Preferred Name

Date of Birth

Country of Birth

Gender

Male
Female
Indeterminate/Intersex/Unspecified

Email Address *

Phone Number *

Home Address

Accommodation

Owned
Rented
Supported Accommodation
Other

Participant Referral Details

NDIS Number *

NDIS Plan Start Date

NDIS Plan End Date

Primary Language

Ethnicity/Culture

Plan Type

Plan Managed
Agency Managed
Self managed

Interpreter Required

Aboriginal and TSI

Is the Participant Referring Themselves?

Plan Manager Name

Plan Manager Email Address

Referring Details / Alternate Contact / Guardianship

Name of Organisation (If Applicable) Job Title/Role

Family Member
Support Coordinator
Case Manager

Referrer Name

Phone Number

Email Address

Alternate Contact/Nominee Name

Relationship to Participant

Alternate Contact Number

Referring Details / Alternate Contact / Guardianship

Is there an Active Guardian?

Guardianship Provisions:

Health
Accommodation
Other

Guardian Name

Relationship

Phone Number

Email Address

Address

General Practitioner Email

Phone Number Address

Clinical Assessment and Diagnoses

Primary Diagnosis:

Secondary Diagnosis:

Goals of Care

Short-Term Goals

How I will Achieve the Goals

How I will be Supported

Medium-Long Term Goals

How I will Achieve the Goals

How I will be Supported

Activities of Daily Living

Communication

Mobility and Transfer

Nutrition & Hydration

Mealtime Supports

Toileting & Continence Management

Personal Hygiene & Grooming(Skin Care/Dressing)

Showers & Bathing

Activities of Daily Living

Oral & Dental Management

Behaviour Management

Individual Daily Planner

Sleep management

Complex Nursing Care/Treatments

Pain Management

Other

AUTHORISATION

Authorised By:

Role

Signed

Date

Participant / Guardian Signature

Date Date for Review

Copy Supplied to Participant?

Copy Placed on Participants File?

MONITORING & SUPERVISION PLAN

Risk Monitoring and Supervision – Participants Living Alone – Sole Support Worker

Participant Risk*			Monitoring Types and Frequencies
Identified Risk	Comment	Risk Level	Communication with participant*			Worker Reports	On-site Monitoring*	On-site Supervision	Other Supervision*
Identified Risk	Comment	Risk Level	Feedback	In-Person	Other (Specify)	Worker Reports	On-site Monitoring*	On-site Supervision	Other Supervision*

COMMUNICATION WITH OTHER PROVIDERS

Information Sharing and Privacy

Ensure the Privacy Policy has been Explained and the Participant Consented to Share Information (page 2).

Provider 1

Provider Name Key Contact Phone Frequency of Contact

Key Contact Name: Key Contact Email: Method of Contact

Provider 2

Provider Name Key Contact Phone Frequency of Contact

Key Contact Name: Key Contact Email: Method of Contact

AUTHORISATION (MONITORING AND SUPERVISION PLAN)

Authorised By:

Role

Signed

Date

Copy Supplied to Participant?

Copy Placed on Participants File?

Date

Date for Review

APPENDIX

CONSEQUENCE RATING TABLE

Use this table as a reference when assessing the risk consequence for each risk identified in the client risk assessment

Consequence Category	Insignificant (1)	Minor (2)	Moderate (3)	Major (4)	Extreme (5)
Client’s Safety	Less than first aid injury or Brief emotional disturbance.	First aid injury	Substantial injury resulting in medical treatment or Temporary impairment or Development /exacerbation of mental illness requiring treatment or Emotional disturbance impacting more than two days – does not require treatment.	Any cases of abuse/neglect of the person. Significant injury causing permanent impairment or Severe, long lasting or significant exacerbation of mental illness requiring long-term treatment or Significant faults allowing significant abuse/neglect of people receiving support.	Avoidable death of a person or Systemic faults allowing widespread abuse/neglect of people receiving support.
Others’ Safety	Nil or minor first aid injury or	First aid injury	Substantial injury resulting in medical treatment or Temporary impairment or	Development /exacerbation of psychological injury requiring treatment.	Preventable fatality.
	Brief emotional disturbance.		Psychological injury impacting more than two days– does not require treatment.	Significant injury causing permanent impairment or Severe, long lasting or significant exacerbation of mental illness requiring long-term treatment.

RISK MANAGEMENT PLANS

RISK MANAGEMENT PLAN

Type of Risk	Likely Effect Level		Risk Treatment (What will be done to Reduce the Risk?)	Person Responsible (Who will do this?)	Review Date (How will this Risk, and Risk Reduction Plan, be Reviewed?)
Type of Risk	Participant 0-5	Others 0-5	Risk Treatment (What will be done to Reduce the Risk?)	Person Responsible (Who will do this?)
Daily Personal Activities Support from Sole Support Worker – Participants Living Alone
Sole support worker risk of neglect or abuse	5	0	Refer to Monitoring and Supervision Plan	Supervisor (name)	Date
Other Risks
Risk of falling due to mobility/ balance challenges	3 (Moderate) or 4 (Major) – could cause Temporary or Permanent Impairment	0 – not Applicable	Handrails in the Client’s Home; Walking Aid/ Panic Alarm; Physical Therapy to reduce fall Likelihood; presence of support workers for higher risk tasks, e.g. showering	Support workers Physiotherapist Key worker to arrange house upgrades and walking aid	Review in 3 months to assess whether any falls have occurred and review risk reduction strategies if these are not working well