ABN 16 271 279 713

NEW PARTICIPANT INTAKE FORM

General Information

Participant Full Name *

Preferred Name

Date of Birth *

NDIS Number *

Contact Phone Number *

Primary Email *

Preferred Method of Contact *

Home Address *

Are you completing this form on behalf of the participant? *

Yes No

Your Full Name *

Relationship to Participant *

Phone Number *

Email Address *

Do you have legal authority to act on behalf of the participant named in this agreement? *

Emergency Contact

Emergency Contact Name *

Relationship to Participant *

Phone Number *

Secondary Emergency Contact (Optional) *

YesNo

Secondary Emergency Contact (Optional)

Phone Number

Are there any restrictions on who we can contact? *

YesNo

Please Provide Details *

Basic Health & Safety Screening

Do you have any allergies? *

YesNo

Please list your allergies *

Do you have any medical alerts we should be aware of? *

YesNo

Please provide brief details *

Do you take regular medication? *

YesNo

Please provide brief details *

Do you have any behaviours of concern we should be aware of? *

YesNo

Please provide brief details *

Are there any environmental risks in the home? (e.g. pets, smoking, hazards, clutter) *

YesNo

Please provide details *

Do you require mobility assistance or use any equipment? *

YesNo

Please describe *

Further details may be requested during onboarding.

About You

What is your primary disability? *

List other disabilities/impairments that affect your day to day functioning.

Further details

Please describe briefly

Are you of Aboriginal or Torres Strait Islander descent? *

Please list any cultural or religious sensitivities to which we should be aware of.

If you're from a linguistically diverse background, please provide details below.

Do you require an interpreter for language or hearing assistance? *

Select the option that best suits your living situation *

Provide details *

NDIS Plan Details

What type of NDIS plan do you have?

Plan Manager Name *

Plan Manager Email

Do you have a Support Coordinator? *

Support Coordinator Name

Support Coordinator Email

NDIS Plan Start Date *

NDIS Plan End Date *

Upload NDIS Plan (optional)

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Your Ongoing Support Preferences

Provide details

Please provide days and times you would like support. *

Do you require gender specific supports? *

Yes - Strictly female only.Yes - Strictly male only.No - I am flexible to meet support workers with the right skills.

Additional information

Consent

I confirm that the above information I have provided is true, complete and accurate. *

I consent to CareSpace collecting and storing my information for the purpose of providing services

Name of signee *

Signature *

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Date *

ABN 16 271 279 713

Director: Jai Smith

Address: 402 Latrobe Tce, NEWTOWN, VIC, 3220

Ph: 0417 949 391

Email: info@carespace.com.au

Please submit your response and a member of the CareSpace team will be in contact within the next 1-3 business days.

Thank you for your time.

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