NDIS Intake Form
Please complete the form below and our team will be in touch with you shortly.
Referrer Details
Referrer: First Name
(Required)
Referrer: Surname
(Required)
Email
(Required)
Phone
(Required)
Relationship to participant
(Required)
-- Select an answer --
Case Manager
Family Member
Legal Guardian
Participant
Primary Carer
Support Coordinator
Other
If other, please describe
Participant Details
Participant: NDIS/NDIA number
(Required)
Participant: First Name
(Required)
Participant: Surname
(Required)
Participant: Preferred First Name
(Required)
Email address
(Required)
Phone number
(Required)
Residential address
(Required)
Date of birth
(Required)
Suburb/ Town
(Required)
State
(Required)
Postcode
(Required)
Preferred method of communication
-- Select an answer --
Email
Post
SMS
Phone
Attach NDIS Plan (or relevant section of the plan)
Max. file size: 50 MB.
Plan Details
Is your plan
Self managed
Portal managed
Using a plan management provider
If plan management provider, who is the provider?
ABOUT THE PARTICIPANT
Marital Status
-- Select an answer --
Single
In a relationship
Married
Widow
Divorced
Separated
Other
Participant living situation
-- Select an answer --
Own home/living alone
Own home/living with family
Living in supported accommodation
Homeless
Temporary(living with friends, family or other accom)
At risk(e.g. evictions, behind in rent, family violence)
Other
Is the participant of aboriginal or torres strait islander descent?
-- Select an answer --
Yes
No
Unknown
Does the participant have a current behavioural support plan?
-- Select an answer --
Yes
No
If other, please describe
Max. file size: 50 MB.
Does the participant have a current behavioural support plan? If yes, please attach the behavioural support plan
Max. file size: 50 MB.
Cognition details
-- Select an answer --
Very good
Own
Fair
Homeless
Poor
Communication
-- Select an answer --
Verbal
Non Verbal
Aids
Other
Hearing impaired interpreter required?
-- Select an answer --
Yes
No
Language Interpreter required?
-- Select an answer --
Yes
No
Is the participant of culturally and linguistically diverse background?
-- Select an answer --
Yes
No
Languages spoken
English
Spanish
Hindi
Arabic
Portuguese
Bengali
Russian
Japanese
Punjabi
Other
If other, which languages?
Personal care - requires assistance with
Shower/Bath
Toileting
Grooming
Dressing
Other
Mobility
Independent
Assist
Walking Stick
Walking Frame
Manual Hoist
Shower Chair
If other, please describe
Formal diagnosis - primary
Formal diagnosis - secondary
Other relevant information about the participant
Do you have any legal issues that may affect services?
Yes
No
(E.G. APPREHENDED VIOLENCE ORDER AVO)
Shifts
Preferred start date
How did you hear about LHS?
-- Select an answer --
Support Coordinator
Friend or Family
Google
Online ads
Facebook
Print Media (LHS Brochures, Newspapers etc)
Other
If other, please describe
Preferred Shifts days and times
Monday - AM
Monday - PM
Monday - Sleepover
Monday - Active Nights
Tuesday - AM
Tuesday - PM
Tuesday - Sleepover
Tuesday - Active Nights
Wednesday - AM
Wednesday - PM
Wednesday - Sleepover
Wednesday - Active Nights
Thursday - AM
Thursday - PM
Thursday - Sleepover
Thursday - Active Nights
Friday - AM
Friday - PM
Friday - Sleepover
Friday - Active Nights
Saturday - AM
Saturday - PM
Saturday - Sleepover
Saturday - Active Nights
Sunday - AM
Sunday - PM
Sunday - Sleepover
Sunday - Active Nights
Shift requirements
What LHS services do you require?
Plan Management (Financial Intermediary)
Support Coordination
Support Workers
Accommodation Services (Supported Living)
List the type of support you need
In-home support
Community access
Personal care
Other
If other support is required, please describe
Who we are
Why we do it
What we offer
Services
Hospital Discharge Nursing Support
24 Hour Support
Supported Independent Living
Respite Support for Families
Community Access and Transport
Pathways Program
Accommodation
Blog
Respite Care
Join Eneca
NDIS Resources
Contact Us
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