Participant Intake Checklist

Date

Staff member completing paperwork

Participant Full Name and/or Nominated Advocate - I have explained the following information to

NDIS No.:

Information explained *

Eligibility criteria for entry to the service, and procedures for prioritising access.The participant’s right to access a support person of their choice to assist them when entering or exiting a service, and in developing their personalised plan.Information and support which can be offered to assist participants using the service.How the service works with participants accessing services to develop a personalised plan to assist them to achieve their goals, and the format of the copy of the plan which will be provided to the participant.Procedures for accessing or nominating a support person of their choice.Support which will be provided, how the support will be delivered, and how frequently the personalised plan will be reviewed.Privacy and confidentiality policy and procedures in relation to the use of, and access to, personal information held about the participant.Procedures for release of personal information to another party and the requirement for informed consent for release.How the participant can participate in decision-making processes to assist the service to improve.

Signed by participant *

Draw signature|Type signatureClear

Date *

Signed by nominated support person

Draw signature|Type signatureClear

Date

This completed checklist is retained on the participant’s file for seven (7) years. Related document: Participant Intake Form; Privacy Policy and Procedure.

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OFFICE USE

Date

Notes