NEW PARTICIPANT INTAKE FORM CLEAR SKY AUSTRALIA NEW PARTICIPANT INTAKE FORM Welcome to Clear Sky Australia
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
NEW PARTICIPANT INTAKE FORM CLEAR SKY AUSTRALIA
NEW PARTICIPANT INTAKE FORM
Welcome to Clear Sky Australia
1
Contact Details
Personal Details
Please list your personal details below
Do you identify as Aboriginal or Torres Strait
Islander?
Country of Birth:
Ethnicity:
Language spoken at home:
Religion:
Please list your contact details below
Form filled date:
Form filled by:
First Name:
Surname:
Preferred Name:
Date of Birth:
Address:
Home Phone:
Mobile Number:
Email Address:
Interpreter Required:
2
Disability
This is my main disability
Tick only 1 box in this column
These are my other disabilities - Tick
each box that applies to you
1. Cognitive or Learning Disability
Acquired Brain Injury
Specific Learning Difficulty (including Attention Deficit Disorder and Dyslexia)
2. Intellectual Disability
Development (0-5)
Intellectual Disability (Including Down Syndrome)
3. Autism Spectrum Disorder
Asperger’s Syndrome
Autism
Pervasive Development Disorder
4. Neurological Disability
Epilepsy
Huntington’s Disease
Multiple Sclerosis
5. Physical Disability
Cerebral Palsy
Motor Neurone Disease
Muscular Dystrophy
Para/Quadri/Tetra Hemiplegia
Non/Verbal Speech Impairment
3
6. Sensory Disability
Deafblind
Blind/Vision Impairment
Deaf/Hearing Impairment
Non/Verbal Speech Impairment
7. Psychiatric and/or other disability not described above (please give details below)
4
NDIS Details
Please provide information in regard to your current NDIS plan
Plan Start Date:
Plan End Date:
NDIS Number:
Self-Managed/Plan Managed:
Commencement date at Clear Sky Australia:
What support Items will you be using with us?
Core Daily Living - Assistance with Daily Life
Daily Living - Transport
Daily Living - Consumables
Social & Community Participation – Assistance with Social & Community Participation
Capital Daily Living – Assistive Technology
Home – Home Modifications and Specialised Disability Accommodation (SDA)
Capacity Building Choice & Control – Support Coordination
Home – Improved Living Arrangements
Increased Social & Community Participation
Finding and Keeping a Job
Improved Relationships
Improved Health and Wellbeing
Improved Learning
Improved Life Choices
Improved Daily Living Skills
5
Emergency Contacts
Contact 1
In the case of an emergency please list your emergency contact details below
Name:
Address:
Home Phone:
Work Pone:
Mobile:
Email:
Relationship:
Contact 2
In the case of an emergency please list your emergency contact details below
Name:
Address:
Home Phone:
Work Pone:
Mobile:
Email:
Relationship:
6
Where Do You Live?
Please complete this section if you are living in Supported Independent Living
Rent/Own/Board/Other:
Type of accommodation:
Housing Contact Name:
Contact Number:
Contact Email:
Address:
What supports are received:
Weekly hours of support:
Other Supports
Please provide any information if you have a COS or a caseworker
Do you have a caseworker/coordination of
supports?
Support Service/Company:
Contact Name:
Contact Number:
Address:
7
Communicating with others
Please provide information around preferred communication methods and strategies
Description of how you communicate with others:
How do people know if you are: happy, sad, angry, sick, in pain, content, anxious/scared/nervous, confused?
What things do you enjoy communicating about?
What are the best ways to help you to understand what others are ‘saying’ to you?
What are the best ways to help you to meet new people at home or in your community?
8
Medical Needs
Please provide information about your current GP doctor
GP Name:
Address:
Phone Number:
Email:
Please list all the information in regards to any special medical needs you may have
Do you have any special medical needs?
Details of provided medical needs:
Do you require medication?
Can you take medication independently?
List of medications you take:
Do you require PRN medication?
Medication that is taken “as needed” are known as “PRN”
medicines.
Summary of PRN medication:
*Please be aware that we require a GP summary of your medication before any services can commence
9
Allergies
Please list all information to any allergies you may have
Do you have allergies?
Description of primary allergy:
Description of trigger for this allergy:
Description of reaction for this allergy:
Description of management of this allergy:
Do you have any other allergies?
Description of next allergy:
Description of trigger for this allergy:
Description of reaction for this allergy:
Description of management of this allergy:
Do you have any other allergies?
Description of next allergy:
Description of trigger for this allergy:
Description of reaction for this allergy:
Description of management of this allergy:
10
Dietary Needs
Please list information in regards to any dietary needs you require
Do you have any specific dietary
needs?
Are you allergic to any foods?
Is there any food you do not like?
Behaviour
Please list information in regard to any specific behaviours
Specific behaviours that the service
provider needs to know about:
Indicated behaviours that apply to them:
Details of behaviour:
Therapy services:
Behavioural Concerns:
Do they have a current behaviour
plan?
If you answered “Yes” to this question services cannot commence until Clear Sky Australia has a copy of this plan.
Do they have a psychologist?
Details of psychologist:
11
Mobility
Please list any mobility needs that you may require
Mobility needs:
Details of mobility needs:
Other Mobility needs:
Details of mobility needs:
Other Mobility needs:
Details of mobility needs:
Therapy Services
Please list any other therapy service that you use – These may include OT services
Service Type:
Contact:
Service Type:
Contact:
Service Type:
Contact:
12
Environmental and Social Risks
Please provide any information around some of these environmental and social risks.
Water/Pools/Ocean
Electricity
Sharp Items
Sun Exposure
Flammables
Traffic/Road Safety
Stranger Danger
Alcohol/Drugs
13
Signature
By signing below, I hereby acknowledge that I have completely read and fully understand the Clear Sky Australia intake form and I also affirm the truth of the following answers.
Name:
Signature:
Who helped to complete this form?
Please list and sign any person that may have helped you complete this form (Include yourself)
Name:
Signature:
Name:
Signature:
Documents
Please list documents that you may have attached to this form
1.
2.
3.
4.
5.
Related Documents
