Complete Choice

0414 890 464 / 0466 057 770

info@completechoice.com.au

39 John St, Salisbury, SA 5108

Participant Intake Form

Participant Intake Form

1. Participant / Consumer Details

Name
Name
First
Last
Gender

Support Coordinator/ Care Manager

Name
Name
First
Last

Participant / Consumer Contact Details

Interpreter required
Preferred option for communication
Do you identify as Aboriginal and Torres Strait Islander?
Is there a Guardianship and/or Administration order in place?
Is there a Behaviour Management Plan in place?

For Participants under the age of 18, under guardianship or in the care of family or caregivers only

Primary Carer
Lives with Participant
Emergency Contact
Relationship to participant

Contact Details

Is their any other Guardian

For Participants under the age of 18, under guardianship or in the care of family or caregivers only

Primary Carer
Lives with Participant
Emergency Contact
Relationship to participant

Contact Details

2. Disability / Medical Conditions including any diagnosis if relevant.

Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

3. Health Care Information

Funding

Managed Type

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIS managed participants)

Maximum file size: 50MB

Self Managed or Plan Managed

Name
Name
First
Last

Maximum file size: 516MB

5. Participant / Consumer Preferences

6. Goals and Aspirations

7. Risk Assessment

Individual Risk Profile

Strategies Developed
Identified in Support Plan

Safety Environment Checklist – Home

Strategies Developed
Identified in Support Plan

I understand that:
  • This organisation owns these records.
  • Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
  • I can ask to see records and receive a copy 
  • Records are archived for a set 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.

Maximum file size: 5MB

Name of the person signing
Name of the person signing
First
Last

Note: Authority to Act as an Advocate form is required if the individual signing this form is not the participant.