Participant Intake Form

Participant intake form

Participant details

Full name *

Preferred name

NDIS number *

Date of birth *

Do you identify as Aboriginal or Torres Strait Islander? *

Gender *

Male FemalePrefer not to sayOther

Other gender (please specify)

Street address *

Town *

State *

Postcode *

Phone number *

Email address *

Nominee or Representative details

Do you have a nominee or representative? *

YesNo

Parent

Guardian

Support person

Plan nominee

Child representative

Emergency contact

Full name

Relationship

Street address

Town

State

Postcode

Phone number

Email address

Is there another nominee or representative? *

YesNo

Parent

Guardian

Support person

Plan nominee

Child representative

Emergency contact

Full name

Relationship

Street address

Town

State

Postcode

Phone number

Email address

NDIS Contacts

Name of support coordinator

Phone number

Email address

Name NDIA planner

Phone number

Email address

Local Area Coordinator Name

Phone number

Email address

Documentation

Upload the participant's NDIS plan *

Browse

Upload any other documentation

Browse

Preferences

Are you religious *

YesNo

Language spoken at home *

English Other

Specify religion

Specify other language

Please add your preferences here Communication preferences, food, staffing, and other preferences.

Please note:

These records are owned by Strength In Care.
Information within these records will be shared with other staff within the organization on and only when staff requires the information to carry out their duties.
The participant can ask to see records and receive a copy.
Records are archived for a set period according to Strength In Care policy and procedures.
All information obtained will be kept confidential.
This information is used to set up the Service Agreement for direct service delivery and/or support coordination services.
The Service Agreement is signed off by both the participant/Advocate and Strength In Care.
A signed service agreement is required to start Strength In Care services.
NDIS standard pricing applies for most services delivered by Strength In Care.

Acknowledgement

Name of person completing the form *

Date form completed *