NDIS New Participant In-take Form

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1. Who is completing this form? (Required.)

Participant

Advocate

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2. NDIS Participant Full Name (Required.)

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3. NDIS Participant's contact phone number (Required.)

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4. Advocates contact phone number (If Applicable)

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5. NDIS Participant Number (Required.)

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6. NDIS Participant's address (Required.)

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7. NDIS Participant’s date of birth (Required.)

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8. NDIS Plan start date (Required.)

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9. NDIS Plan end date (Required.)

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10. Would you be willing to share a copy of your NDIS Plan to help us better assist you with services? (Required.)

Yes

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11. Which NDIS Services are needed? (Tick all that apply) (Required.)

Assistance with Daily Living: Assistance with daily activities, such as personal care, medication assistance and mobility

Social and Community Participation: Assistance in participating or accessing social and community activities,
such as shopping, medical appointments, social events and transport assistance

Activity Based Transport: Transportation services to and from your chosen destination

Domestic Assistance: Light house cleaning, dusting, vacuuming, mopping and laundry assistance

Household and Yard Maintenance: Assisting with household and yard maintenance, lawn-mowing, rubbish removal
and gardening

Therapies: Physiotherapist, psychologist, occupational therapy and therapy assist, assistive technology assessment,
dietician and other allied health services

Support Coordination: Assistance with organising support funding and accessing a range of supports to meet individual needs and goals

Comments:

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12. When would you like to start receiving services? (Required.)

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13. Preferred Service Days (Tick all that apply) (Required.)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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14. Are there any risks or hazards to be aware of? (i.e. Pets) Please provide details: (Required.)

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15. Please specify support worker preferences or requirements (If any): (Required.)

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16. Please provide a brief description of the participant: (Required.)

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17. NDIS Plan Manager details (select all that apply) (Required.)

NDIS managed

Self-Managed

Plan Managed by a specific provider or nominee (please name Provider or Nominee)

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18. Support Coordinator Details: (Required.)

I don't have a support coordinator

I have a Support Coordinator (Please provide their name and contact number)

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19. Advocate details: (Required.)

I don't have an advocate

I have an advocate (please provide advocate's name and contact number)

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20. Emergency contact name: (Required.)

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21. Emergency contact number: (Required.)

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22. Relevant medical information and/or allergies (Required.)

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23. Does the participant have a current Behavioural Plan (BSP)? (Required.)

Yes

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24. Preferred contact method: (Required.)

Phone

Website Chat

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25. Preferred contact time: (Required.)

Morning

Midday

Afternoon

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26. How did you hear about us? (Required.)

Word of mouth

Google search

Facebook Advertisement

Instagram Advertisement

YouTube

Referral from another service provider

NDIS New Participant In-take Form

Question Title

* 1. Who is completing this form? (Required.)

Question Title

* 2. NDIS Participant Full Name (Required.)

Question Title

* 3. NDIS Participant's contact phone number (Required.)

Question Title

* 4. Advocates contact phone number (If Applicable)

Question Title

* 5. NDIS Participant Number (Required.)

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* 6. NDIS Participant's address (Required.)

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* 7. NDIS Participant’s date of birth (Required.)

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* 8. NDIS Plan start date (Required.)

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* 9. NDIS Plan end date (Required.)

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* 10. Would you be willing to share a copy of your NDIS Plan to help us better assist you with services? (Required.)

Question Title

* 11. Which NDIS Services are needed? (Tick all that apply) (Required.)

Question Title

* 12. When would you like to start receiving services? (Required.)

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* 13. Preferred Service Days (Tick all that apply) (Required.)

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* 14. Are there any risks or hazards to be aware of? (i.e. Pets) Please provide details: (Required.)

Question Title

* 15. Please specify support worker preferences or requirements (If any): (Required.)

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* 16. Please provide a brief description of the participant: (Required.)

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* 17. NDIS Plan Manager details (select all that apply) (Required.)

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* 18. Support Coordinator Details: (Required.)

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* 19. Advocate details: (Required.)

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* 20. Emergency contact name: (Required.)

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* 21. Emergency contact number: (Required.)

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* 22. Relevant medical information and/or allergies (Required.)

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* 23. Does the participant have a current Behavioural Plan (BSP)? (Required.)

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* 24. Preferred contact method: (Required.)

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* 25. Preferred contact time: (Required.)

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* 26. How did you hear about us? (Required.)

1. Who is completing this form? (Required.)

2. NDIS Participant Full Name (Required.)

3. NDIS Participant's contact phone number (Required.)

4. Advocates contact phone number (If Applicable)

5. NDIS Participant Number (Required.)

6. NDIS Participant's address (Required.)

7. NDIS Participant’s date of birth (Required.)

8. NDIS Plan start date (Required.)

9. NDIS Plan end date (Required.)

10. Would you be willing to share a copy of your NDIS Plan to help us better assist you with services? (Required.)

11. Which NDIS Services are needed? (Tick all that apply) (Required.)

12. When would you like to start receiving services? (Required.)

13. Preferred Service Days (Tick all that apply) (Required.)

14. Are there any risks or hazards to be aware of? (i.e. Pets) Please provide details: (Required.)

15. Please specify support worker preferences or requirements (If any): (Required.)

16. Please provide a brief description of the participant: (Required.)

17. NDIS Plan Manager details (select all that apply) (Required.)

18. Support Coordinator Details: (Required.)

19. Advocate details: (Required.)

20. Emergency contact name: (Required.)

21. Emergency contact number: (Required.)

22. Relevant medical information and/or allergies (Required.)

23. Does the participant have a current Behavioural Plan (BSP)? (Required.)

24. Preferred contact method: (Required.)

25. Preferred contact time: (Required.)

26. How did you hear about us? (Required.)