Participant Discovery Form

PARTICIPANT DETAILS

Participant’s First Name *

Preferred Name

Participant's Last Name *

Date of Birth *

Gender *

Preferred Pronouns Eg. He/Him, She/Her, They/Them

Email Address: *

Phone *

Address *

Street address *

City *

State *

Postcode *

Postal Address (If different to above)

Post Code (If different to above)

Does the participant identify as: *

NoAboriginalTorres Strait IslanderI prefer not to answer

Any Cultural Background and/or Preferences

Who does the participant live with? *

Does the participant have a Taxi Card? *

YesNo

Does the participant have a disability pension? *

YesNo

Any Triggers? Eg.: Bright Lights

Mobility Challanges?

Are you left or right-handed? *

Left-handedRight-handedBothNeither

Does the participant have a Companion Card? *

YesNo

Any preferred correspondence requirements?

EMERGENCY INFORMATION

Emergency Contact 1

First Name *

Surname *

Phone *

Email

Relationship *

Emergency Contact 2

First Name *

Surname *

Phone *

Email *

Relationship *

HEALTH AND MEDICAL INFORMATION

Disability *

Allergies

Dietary restrictions / requirementsEg.: Can't drink soda, unable to consume drink with artificial sweetener

Medical Alerts

Upload any relevant documents Eg.: Asthma Plan, Epilepsy Plan etc

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Medication

Does the participant take any medication? *

YesNo

DetailsPlease note HappinessFirst can not store, provide nor administer any medications.

COMMUNICATION

Communication NeedsE.g: IPad with ABC App, Sign Language, Interpreter

Preferred option for communication *

Phone/MobileSMSEmailPost

Does the participant have any hearing challenges?

LEGAL ORDERS

Is there a

Guardianship in place?Administration Order?Power of Attorney?Other - load document

Upload any relevant documents

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NDIS DETAILS

NDIS Number: *

Start date of NDIS Plan *

End date of NDIS Plan *

Upload a copy of your NDIS Plan

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How is your funding managed? *

Self-ManagedPlan Managed

Name of person/organisation to email invoices to:

Phone

Email invoices to:

Do you authorise HappinessFirst to discuss NDIS relevant and reasonable information with your listed plan manager?

YesNo

Do you have a Support Co-ordinator? *

YesNo

Persons Name

Company Name (if relevant)

Phone

Email

Do you authorise HappinessFirst to discuss NDIS relevant and reasonable information with your listed support coordinator?

YesNo

DESIRED SCHEDULE OF SUPPORT - DATES & TIMES

How can we support you / which days / times E.g: Take me shopping, home care, supported employment

Do staff need to wear PPE while supporting you? *E.g: mask, gloves

RELEASE OF PERSONAL INFORMATION TO THIRD PARTIES

If you are consenting to the Release of Personal Information to Third Parties

You choose to:

Pursuant to The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information Protection Act when you request third parties to either advocate or make inquiries to our organisation on your behalf, you must provide your consent (via the following form) for us to release your personal information to the third party.
In all cases, our organisation will only release as much information as is needed to respond to the inquiry or concern. However, certain information will not be released by the organisation (e.g., information about other individuals, records subject to solicitor-participant privilege, records relating to a current lawful investigation, records the release of which would affect the safety or health of anyone). Note: If the same third party makes a subsequent, but unrelated, inquiry you will need to complete this form again.
The purpose of the Consent to Release Personal Information to a Third-Party form is to provide consent to the release of personal information to third parties as requested by you is protected and governed by the privacy provisions of The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth).e
I understand the above information request may include personal information within the meaning of the Freedom of Information and Protection of Privacy Act 2012 (Cth) the Privacy Act 1988.
I further understand that the organisation will only release as much information as is needed to respond to my concern and subject to the restrictions and provisions of the Freedom of Information and Protection of Privacy Act 2012 (Cth) the Privacy Act 1988.

Include the person and organisations name, phone number, email (or preferred communication) and relationship (e.g - OT, teacher).

CONSENT

Do you give us authority to use photographs and/or video for sharing & marketing purposes? Like on Facebook or Instagram or on the office screen? *

Yes Yes - but don't use my name.No

Can we put your photo on our office/cafe display tablet?

YesNo

RISK SUMMARY

Outline any potential risks identified and strategies to mitigate them.

Any Challenging Behaviours?

This could include things like:

Self-harm
Suicide Risk
Assault - Physical and/or Verbal (self or others)

Is there any challenging behaviour? *

Yes - If yes, complete belowNo

Describe any Challenging Behaviours (only if an issue)

Behaviour Risk Level

HighMedLow

Behaviour Action Plan

Challenges with movements & spacial awareness?

Trip/Fall risk
Startle/Panic Behaviour
Scraching or pulling peple
Sudden movements including grabbing, holding or leaning
Challanges with walking stability

Is there any challenges with movements & spacial awareness? *

Yes - If any, complete belowNo

Describe any Challenges with movements & spacial awareness (only if an issue)

Risk Level

HighMediumLow

Action Plan

Recuring challenges with:

Dysphagia- (choking at mealtimes)
Choking risk
Nutritional risks (foods or drinks not allowed to be consumed)
Swallowing risk
Eating Disorder

Are there any recurring challenges with the above? *

Yes - If any, complete belowNo

Describe any challenges (only if an issue)

Recurrent Conditions risk level

HighMediumLow

Recurrent Conditions Action Plan

Any Resistance to Support During Activities of Daily Living?

Feeding
Toileting
Personal Hygiene (including showering, bathing and grooming)
Fire/Emergency evacuation

Are there any resistance to support during activities of daily living? *

Yes - If any, complete belowNo

Describe Any Resistance to Support During Activities of Daily Living (only if an issue)

Resistance to Support During Activities of Daily Living Risk Level

HighMediumLow

Resistance to Support During Activities of Daily Living Action Plan

Any Manual Handling Risks?

Transfers/ Moving in Bed
Mobility
Vehicle Access
Personal Care tasks

Are there any manual handling risks? *

Yes - If any, complete belowNo

Describe any Manual Handling Risks (only if an issue)

Manual Handling Risks Level

HighMediumLow

Manual Handling Risks Action Plan

Any Community Access Risks?

If in the Community without a Support Worker (SW), will the participant become lost or unable to get home?
Are there any risks associated with Community Access
- during the Day or Night
- using public transport
- Road saftey when walking
- concept of time

Are there any community access risks? *

Yes - If any, complete belowNo

Describe Any Community Access Risks (only if an issue)

Community Access Risk level

HighMediumLow

Community Access Risks Action Plan

Would you like to provide any further information?

Please upload a copy of any additional Risk Assessment material including any Behaviour Management Plan

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NEXT STEP

I understand that a member from the HappinessFirst team will call me within the next 24 business hours to book in my Participant Induction. Participant Inductions take 1-2 hours with two staff members, this is charged at <time taken> x 2 staff.
Line item - 04_104_0125_6_1 Access Community, Social And Rec Activities - Standard - Weekday Daytime *

THIS AGREEMENT

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All the information I've provided is true and accurate. I have answered to the best of my ability.

Nominate an advocate
An advocate is a person who will listen to you, help you make decisions about what should happen in your life and then speak, on your behalf, to arrange for those secisions to be implemented. An advocate will ensure that your rights are respected and speak out for you if your needs are not met.
*

Advocate's Full Name

Advocate's Email

Advocate's Phone

Advocate's Address

Street address

City

State

Postcode

Advocate

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Date

Participant's Full Name *

Participant Signature *

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Date *

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