Intake Questionnaire and Referral Form

Participant details

Full Name *

Date of Birth

Phone *

Email *

Residential Address

2. NDIS Information

Plan Number

Plan Start Date

Plan End Date

Plan Management

Plan Manager

NDIA Managed

Self-Managed

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

Guardian Full Name

Relationship to Participant

Parent

Guardian

Caregiver

Other

Best Contact Number

Email Address

Residential Address

3. Personal Information

Services

Personal Care Activities – Activities of Daily Living

Personal Care Activities – Activities of Daily Living ☐

Meal Planning and Preparation

Grocery Shopping

Support to Develop Social Networks and Friendships ☐

Assistance with Medical Needs

Assistance with Daily Life Tasks in a Group or Shared Living Arrangement (SIL)

Participation in Community, Social and Civic Activities

Bowel care incl Stoma Care

Catheter care

Palliative Care

Wound and Pressure Area Management

PEG Feeding

Diabetes Care

Seizure Care

Transport – Wheelchair accessible Van, Non Modified vehecle ☐

Mealtime Management Care (swallowing, diabetes, allergy/anaphylaxis, diabetes, CV Disease, obesity)

Implementation of a Restrictive Practice

Other

Personal Preferences

Preferred or Chosen Name

Spiritual & Religious Needs

Cultural Requirements

Communication Aids

Physical Support Needs

Other Details We Need To Know

Goals and Aspirations

Goals to Achieve (Immediately)

Goals to Achieve (6 Months Timeframe)

Goals to Achieve (By Next Year)

Invoicing / Billing Information

Name of Billing Contact

Name of Company or Organisation

Invoicing Email Address

Important Details or Comments

I understand that:

These records are owned by the Provider Flonac Health Services
Information within these records will be shared with other staff within the organisation if/when staff require the information to carry out their duties
I can ask to see records and receive a copy at any time
Records are archived for a set time 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:

Participant or Representative Signature

Clear

Full Name of Person Signing

Relationship to the Participant (if not the participant)

Date Of Submission