First Name: Last Name: Gender: Date of birth: Address: Suburb: Postcode: State: Contact Number: Email Address: Preferred method of communication: Phone SMS Email Mail NDIS Number: NDIS Funding Type: Self Managed Plan Managed NDIA Managed If applicable, Plan Manager/ Plan Nominee details: Name: Organisation: Email: Contact Number: Plan Start Date: Plan End Date: Personal Details Aboriginal or Torres Strait islander descent? Yes No Living Situation Own home (living alone} Own home ( living with family) Living in supported accomodation Temporary ( relatives, friends, or other) At risk Home less Other: Do you have a current Behavioural Support Plan? Yes No Primary Formal Diagnosis: Secondary Formal Diagnosis: Are there any legal issues that may affect our service? If applicable, please provide details Other relevant information: REPRESENTATIVE OR EMERGENCY CONTACT DETAILS Contact 1: Advocate Parent Guardian Support person emergency contact Plan nominee Other Contact 2: Advocate Parent Guardian Support person emergency contact Plan nominee Other Name: Name: Relationship to client: Relationship to client: Address: Address Contact Number Contact Number Email Email Advocacy Form Supplied?: Yes No Advocacy Form Supplied?: Yes No COMMUNICATION Type: Verbal Non Verbal Communication aids required Other Languages Spoken English Other Is an Interpreter required? No Language Hearing Impaired PHYSICAL HEALTH Asthma Diabetes Epilepsy Heart Conditions Visual Impairment Cognitive Impairment Blood Disorders Sleep Apnoea Other: Medications - If applicable, please list: I would like assistance with managing this by: MENTAL HEALTH Depression Anxiety Post-Traumatic stress disorder Bipolar Psychosis Schizophrenia Obsessive compulsive disorder Mood disorder Other Medications - If applicable, please list: History of Hospital admission Yes (please provide further details) No I would like assistance with managing this by : DIETARY REQUIREMENTS Any dietary requirements Yes No Vegetarian Yes No Vegan Yes No Dairy Free Yes No Gluten Free Yes No Allergies - If applicable, please list: I do not like to eat: (please list) My favourite food is: PRACTICAL SUPPORT NEEDS I require assistance with : Mobility Independent Assist Walking stick Walking frame Manual hoist Shower chair Other Personal Care Shower/Bath Toileting Grooming Dressing Other What A Disability Community Pty Ltd services do you require? In-Home and Community Supports Assistance in Coordinating or Managing Life Stages, Transitions And Supports Daily Personal Activities Assistance with Travel/Transport Arrangements Innovative Community Participation Development of Daily Living and Life Skills Household Tasks Participation in Community, Social and Civic Activities High Intensity Daily Personal Activities Supported Independent Living/Respite Care/Short Term Accommodation/Group Assistance with Daily Life Tasks in a Group or Shared Living Arrangement Group and Centre Based Activities Employment related supports Assistance to Access and Maintain Employment or Higher Education Specialised Supported Employment Professional Registration Groups Implementing Behaviour Support Plans Community Nursing Care Specialised Support Coordination Early Childhood Supports A Disability Community Pty Ltd can assist me by …. YOUR PREFERENCES Do you have specific preferences when matching our staff with you?: Gender Male Female No preference Age group: Culture/Religion/Ethnicity Languages spoken Personality characteristics Specific needs, skills or knowledge required? Specific training that may be required to provide services and support to you? Is there anything else you would like us to know about you that is important for how we provide our services to you? What are your goals, expectations and desired outcomes when receiving our services? What are your goals for the next 12 months? CONSENT & ACKNOELEDGEMENT By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan. Do you consent to participating in and use of: ☐ Participating in audits of our business by the NDIS Commission and its auditors ☐ Photos (This may include website, social media or marketing materials) ☐ None of the above Signed by the client Date Name (please PRINT) Signed by the represenive Date Name (please PRINT) Signed for and on behalf of A Disability Community Pty Ltd ABN 63689835863: Date Name (please PRINT) Submit
