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Intake Form

Intake Form
Referrals Form
Complaints / Providing Feedback
Client Satisfaction Survey

intake Form

It's simple to refer to D&AC Services. Just complete the form below and our friendly team will get in contact with you.

1. Is there a Positive Behaviour Support Plan (PBSP) in place or under development?

If yes, what kind of PBSP?

Interim Comprehensive Not sure

Does the PBSP include restrictive practices? *

Yes No Not sure

2. Is there an authorisation in place for use of restrictive practices?

3. Are there any known behaviour/s of concern?

a. What are the behaviour/s?

b. How often does the behaviour/s occur?

c. How is/are the behaviour/s managed / what is the normal intervention?

4. Does the person have a diagnosed mental health condition?

If yes, please specify:

5. Is some or all the funding in your NDIS plan managed by the National Disability Insurance Agency (NDIA)?

If yes, please specify:

6. Does your NDIS plan require that one or more items of support must be provided by a registered NDIS provider?

If yes, please specify:

Referrer Details

Referrers First Name

Referrers Email

Referrers Last Name

Referrers Phone

Referee's Organisation / Other

Who is the Referrer?

If other, please specify

What Services are you Interested in?

What services are you interested in?

Core Support Services

Social & Community Participation

Allied Health

Participant Information

NDIS Number

Firstname

Mobile

NDIS Plan Start Date

Surname

Home Number

NDIS Plan Finish Date

Date of Birth

Address

City

ZIP/Postal Code

Gender

Male Female Other

If other, please specify

Do you identify as Aboriginal and Torres Strait Islander?

Yes No

Preferred option for communication

Post

Phone

State/Province

Country

Are you from a Cultural and Linguistically Diverse (CALD) Background?

Yes No

Language spoken at home

Interpreter Required

Yes No

Disability/Medical Conditions including any diagnosis if relevant

Any additional information, brief or comments

other service providers currently using

Name

Address

Phone Number

Frequency of Use

health care information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

Doctor Name

Address

Phone Number

funding

NDIS Information

Is the client a participant of the National Disability Insurance Scheme?

Yes

Unsure

NDIS Funding Status

Funding

NDIS Managed

Self-Managed

Plan-Managed

NOTE: A copy of the NDIS plan MUST BE provided, so that a service agreement can be generated.

Organisation / Providers Name

Contact Person

Address

Phone (Business Hours)

Alternative Contact Person

Website Address

Mobile

Comments

preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communicatoin device

Physical Assistance

Other Considerations

goals and aspirations

What do you want to achieve yourself - life skills, physically, socially etc?

Immediately

In 6 months

Next year

Consent

I understand that these records are owned by this organisation

I understand that information withese these records wll be shared with other staff within the organisation on and only when staff require the information to carry out their duties

I understand that I can ask to see records and receive a copy

I understand that records are archived for a set period according to policy and procedure

I understand that all information obtained will be kept confidential

Relevant Documents

Please Attach NDIS Plan, Allied Health Reports, and any other documents
NOTE: Please upload one document per "Upload File" Button.

Signature of Participant or Parent/Caregiver

Name

Date

Relationship to participant

I give consent to share my client's or participant's information with relevant stakeholders

Yes

I agree to have my details saved

Email address

ACKNOWLEDGEMENT OF COUNTRY

D&AC SERVICES ACKNOWLEDGES AND RECOGNIZES THE TRADITIONAL OWNERS OF THE LAND UPON WHICH WE LIVE AND WORK, AND WE PAY OUR RESPECTS TO THEIR ELDERS BOTH PAST, PRESENT AND FUTURE.

OUR VETERANS