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- Policy Form
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HOME
About Us
Client Intake
Join Us
Report An Incident
Progress Notes
Request Forms
Download Forms
- Participant Documents
- Policy Form
Upload Forms

Participant Intake Form

PARTICIPANT DETAILS

First Name: *

Last Name:

Gender: *

Date of Birth *

Address: *

Suburb:

State/Province *

ZIP / Postal Code

Contact Number: *

Email address: *

Preferred method of communication *PhoneSMSEmailMail

NDIS Number: *

NDIS Funding Type: *Self ManagedPlan 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? *YesNo

Living Situation *Own home (living alone)Own home (living with family)Living in supported accommodationTemporary (relatives, friends or other)At riskHomelessOther:

Other Living Situation *

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 OR EMERGENCY CONTACT DETAILS

CONTACT 1: *AdvocateParentGuardianSupport PersonEmergency ContactPlan NomineeOther:

Name:

Relationship to Client:

Address:

Contact Number:

Email:

CONTACT 2:AdvocateParentGuardianSupport PersonEmergency ContactPlan NomineeOther:

Name:

Relationship to Client:

Address:

Contact Number:

Email:

Advocacy Form Supplied? *YesNo

COMMUNICATION

Type *VerbalNon-VerbalCommunication aids requiredOther:

Other Type? *

Languages Spoken *EnglishOther:

Other Languages *

Is an Interpreter required? *NoLanguageHearing impaired

PHYSICAL HEALTH *AsthmaDiabetesEpilepsyHeart ConditionsVisual ImpairmentHearing ImpairmentCognitive ImpairmentBlood DisordersSleep ApnoeaOther:

Other Physical Health? *

Medications *

I would like assistance with managing this by: *

MENTAL HEALTH *DepressionAnxietyPost-traumatic stress disorderBipolarPsychosisSchizophreniaObsessive compulsive disorderMood DisorderOther:

Other Mental Health *

Medications *

History of hospital admission? *YesNo

Please provide further details *

I would like assistance with managing this by:

DIETARY REQUIREMENTS

Any dietary requirements *YesNo

Vegetarian *YesNo

Vegan *YesNo

Dairy free *YesNo

Gluten free *YesNo

Allergies

I do not like to eat:

PRACTICAL SUPPORT NEEDS

Mobility *IndependentAssistWalking StickWalking FrameManual HoistShower ChairOther:

Other Mobility *

Personal Care *Shower/BathToiletingGroomingDressingOther:

Other Personal Care *

My favorite food is: *

What Enable, Independent Living, Housing and Support Services services do you require? *In-Home and Community SupportsSupported Independent Living/Respite Care/GroupEmployment related supportsProfessional Registration GroupsSpecialist Disability Accommodation

1. Assistance in Coordinating or Managing Life Stages, Transitions and Supports2. Daily Personal Activities3. Assistance with Travel/Transport Arrangements4. Development of Daily Living and Life Skills5. Household Tasks6. Participation in Community, Social and Civic Activities

1. Assistance with Daily Life Tasks in a Group or Shared Living Arrangement2. Group and Centre Based Activities

1. Assistance to Access and Maintain Employment or Higher Education2. Specialised Supported Employment

1. Specialist Behaviour Support2. Implementing Behaviour Support Plans3. Therapeutic Supports4. Specialised Support Coordination

Enable, Independent Living, Housing and Support Services can assist me by …. *

YOUR PREFERENCES

Do you have specific 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? *

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 auditorsPhotos for Social MediaPhotos for our websiteNone of the above

Signed by the Client:

Signature: *

Date: *

Signed by the Representative

Signature: *

Date: *

Signed for and on behalf of Enable, Independent Living, Housing and Support Services ABN 45 134 455 539:

Signature: *

Date: *

Address

AMP Building, Level 10, 1 Hobart Place Canberra City ACT 2600 Main house in Macquarie, ACT 2614

PO Box: 4253 Ainslie ACT 2602

Contact Info

Phone: 0450 440 408
Email: info@enableilhss.com.au

All Rights Are Reserved To Enable, Independent Living, Housing and Support Services