Participant Intake Form

Step 1 of 13

1. Participant Details

Participant Name(Required)

First Last

Date Of Birth(Required)

Day

Month

Year

Gender(Required)

Home Phone

Mobile Phone

Language spoken at home(Required)

Interpreter required(Required)

Yes

Preferred option for communication(Required)

Post

Phone

Do you identify as Aboriginal and Torres Strait Islander?(Required)

Yes

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service requested(Required)

Is there a Guardianship and/or Administration order in place?(Required)

Yes

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

Name

First Last

Primary Carer

Yes

Lives with Participant

Yes

Emergency Contact

Yes

Relationship to participant

Parent

Guardian

Caregiver

Other

Residential Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone

Home Phone

Who do we contact to schedule a visit?(Required)

Participant

Representative

Housing facility manager

Other

Name(Required)

First Last

Contact details(Required)

2. Referrer details

Name of organisation (Referrer)(Required)

Name of individual referring(Required)

Relationship to client(Required)

Referrer Phone(Required)

Referrer Email(Required)

Is the client aware of the referral(Required)

Yes

3. Disability / Medical Conditions including any diagnosis if relevant.

Give Details

Other service providers currently using

Name

Address

Phone number/email

Frequency of use:

(add others as appropriate)

Does this participant have a history of violence or sexual assault towards others?(Required)

Yes

If yes, please provide relevant details

While Highlands Care Services understands the right to privacy of participants, we also have an obligation to protect our staff. Any information disclosed will be only be used to determine levels of service required.

4. Health Care Information

Doctor Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

5. Letter of authority (required for catheter, PEG or tracheostomy changes)

Type

Date received

Day

Month

Year

Comments

6. Risks to transition or Exit

Transition Risks to participants

7. Living arrangements

Living situation(Required)

Alone

Spouse/partner

Children

Relatives

Unknown

Other

Usual accommodation setting(Required)

Own home

Rental

RAC

Retirement village

Boarding Home

Mobile Home

Public

Other

8. Funding

Plan(Required)

Self-Managed

Plan Managed

NDIS Managed

NDIS Number:(Required)

NDIS Start Date(Required)

Day

Month

Year

NDIS End Date(Required)

Day

Month

Year

Plan Manager(Required)

Support co- ordinator(Required)

Funding to be taken from(Required)

Core

Plan Managed

Please provide details for invoices

Name(Required)

First Last

Email(Required)

Comments(Required)

To whom should we send clinical reports(Required)

Support co-ordinator

Support person

Other

9. Personal Preferences

Preferred name(Required)

Religious Requirements

Cultural Requirements

Communication device

Physical Assistance

Other Considerations

10. Goals and Aspirations

What do you want to achieve for yourself – life skills, physically, socially etc?(Required)

Immediately(Required)

In 6 months(Required)

Next year(Required)

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:

This form was completed by

Name(Required)

First Last

Date

Day

Month

Year

Relationship(Required)

My relationship to this person is (Self / Parent / Support Coordinator/ Carer / Guardian etc.)

1. Participant Details

2. Referrer details

3. Disability / Medical Conditions including any diagnosis if relevant.

4. Health Care Information

5. Letter of authority (required for catheter, PEG or tracheostomy changes)

6. Risks to transition or Exit

Transition Risks to participants

7. Living arrangements

8. Funding

9. Personal Preferences

10. Goals and Aspirations

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

This form was completed by

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