NDIS Intake Form

Referrer Details

Referrer: First Name(Required)

Referrer: Surname(Required)

Email(Required)

Phone(Required)

Relationship to participant(Required)

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

Attach NDIS Plan (or relevant section of the plan)

Max. file size: 50 MB.

Plan Details

If plan management provider, who is the provider?

ABOUT THE PARTICIPANT

Marital Status

Participant living situation

Is the participant of aboriginal or torres strait islander descent?

Does the participant have a current behavioural support plan?

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

Communication

Hearing impaired interpreter required?

Language Interpreter required?

Is the participant of culturally and linguistically diverse background?

If other, which languages?

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?

(E.G. APPREHENDED VIOLENCE ORDER AVO)

Shifts

Preferred start date

How did you hear about LHS?

If other, please describe

Shift requirements

If other support is required, please describe