Participant Details

First name*

Last name*

Date of birth*

Day/Month/Year

NDIS Number*

Preferred language

Cultural background preference

Sex recorded at birth

Gender identity

Please share your pronouns

Contact number

Residential address

Suburb

State

Post code

Living Arrangements

Living arrangements

Alone

Couch surfing

Family / partner

Supported accommodation

Other (please specify)

SUPPORT REQUESTED

NDIS Plan Details

Plan manager details

Do you require assistance to set up a plan manager?

Plan Start

Day/Month/Year

Plan End

Day/Month/Year

NDIS Plan

Sharing a copy of your NDIS Plan is important, this allows us to understand your goals.

Your plan, as with all your information remains confidential, we do not share any of this information without your consent.

Additional Support

Emergency contact name

Contact number

Relationship to participant

Referrer name

Contact number

Relationship with participant

Can you sign documents on behalf of the participant?

Yes

Safety Information

Any risk of self-harm identified?*

Yes

Are there any pets on the property?*

Yes

Any harm to others identified?*

Yes

Any harm from others identified?*

Yes

Are there any firearms on the property?*

Yes

Is there any history of current use of drugs at this property?*

Yes

Any risk support staff need to know?*

Yes (details below)

Does the participant display any challenging behaviours?*

Yes (details below)

Additional safety information

Medication/Mealtime Information

When eating or drinking, do you ever have trouble swallowing?*

Yes

Do you avoid any foods because they are hard to eat or give you any type of side effects?*

Yes

Does it feel like food or drink gets stuck in your throat?*

Yes

Do you ever regurgitate your food or drink?*

Yes

Do you take medication?*

Yes

Do you independently take medication?*

Yes

Additional notes

* Denotes Mandatory questions