HappinessFirst Pty Ltd

Participant Intake Form

Participant Details

Participant’s name *

Date of birth *

Identifies as *

Phone – Home

Mobile

Email address *

NDIS Number *

Language spoken at home *

Interpreter required *

YesNo

Identifies as Aboriginal and Torres Strait Islander *

YesNo

Residential Address *

Street address *

City *

State *

Postcode *

Postal Address (if different from above)

Street address

City

State

Postcode

Is there a Guardianship and/or Administration order in place? *

YesNo

Is there a Behaviour Management Plan in place? *

YesNo

Parent / Guardian 1

Full Name

Primary Carer

YesNo

Lives with Participant

YesNo

Emergency Contact

YesNo

Relationship to participant

ParentGuardianCaregiverOther

Residential Address

Street address

City

State

Postcode

Postal Address (if different)

Street address

City

State

Postcode

Phone – Home

Mobile

Email address

Parent / Guardian 2

Full Name

Lives with Participant

YesNo

Emergency Contact

YesNo

Relationship to participant

ParentGuardianCaregiverOther

Primary Carer

YesNo

Residential Address

Street address

City

State

Postcode

Postal Address (if different)

Street address

City

State

Postcode

Phone – Home *

Mobile *

Disability / Medical Conditions including diagnoses (if applicable)

Tell us a little about ..

Medications

Medication Assessment Tool - if not needed just answer NO

Strategies Developed

Identified in Support Plan

Medication Plan and Consent Form

YesNo

Self-Administration of Medication Assessment

YesNo

Risk Indemnity Form

YesNo

Behaviour Support

Behaviour Support Plan documents collected for authorisation purposes (if relevant)

YesNo

Behaviour Support Plan available on NDIS portal

YesNo

Other Service Provider

Organisation Name

Phone Number

Email

Services used & Frequency of Use

Other Service Provider

Organisation Name

Phone Number

Email

Services used & Frequency of Use

Health Care Information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership Number

Reference Number

Doctor’s Name *

Phone Number *

Email *

NDIS Funding

Self-ManagedPlan-ManagedNDIA-Managed

NDIS Number *

NDIS Plan Start Date *

Invoices – Name *

Invoices – Email *

Additional Information

Upload a copy of your NDIS plan

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Personal Preferences

Preferred Name

Religious Requirements

Cultural Requirements

Communication Aid

Physical Assistance

Other Considerations

Personal Goals

Describe your personal goals (life skills, physical, social) *

Immediately

In 6 months

Next year

Risk Assessment

Risk Assessment Tool - if not needed just answer NO

Strategies DeveIoped

Identified in Support PIan

Individual Risk Assessment Profile

YesNo

Safe Environment Checklist – Are supports delivered at the participants home?

YesNo

Participant Safe Environment Risk Assessment

YesNo

Nutrition and Swallowing Risk Checklist

YesNo

NDIS Audit (opt-out) - We are seeking to confirm if you give your consent for the auditors to contact you and review your file and records. Your participation is not compulsory – you can opt out if you do not want to be involved.

Select Opt Option

In Out

Acknowledgment

I understand that:

HappinessFirst Pty Ltd owns these records.
Information within these records will be shared with other relevant workers within the organisation only when the relevant worker requires the information to carry out their duties and provide safe and quality services and support.
I can ask to see my personal records at any time, and receive a copy for my records.
My personal records are archived for a set period according to legislative and organisational policy requirements.
All information obtained will be kept secure, private and confidential.

To the best of my knowledge, the information provided in this form is true and correct:

Date

Participant's Name

Participant’s Signature

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Name of the Person Signing (if not the participant)

Relationship to the Participant (if not the participant)

Authorised Representative’s / Parent’s Signature (if applicable)

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

This completed Participant Intake Form is retained for seven (7) years.

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