Client Information Form

Client DETAILS

First Name

Last Name

Preferred Name

Date of Birth

English is a Second Language

YesNo

Ethnicity

ATSI

AboriginalTorres Strait IslanderNone of the Above

Client CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

Postcode

City / Suburb

State

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Home Phone

Mobile Phone

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

Guardian details / Support coordinators details

Guardian details

Email address

Phone number

Support coordinators details

Email address

Phone number

NDIS DETAILS

Are you and NDIS participant *

YesNo

NDIS NUMBER *

NDIS PLAN DATES *

How is the Plan managed *

Plan Managed Self managedAgency Managed

Email address for invoices *

Other funding types

Are you privately funded

YesNo

Email address for invoices

Age Care package held by

Care coordinator contact

Invoices to be sent to

Medical information

Medical Information

Please list the following

Diagnosis
Allergies
Additonal relevent medical information
Medications and their purpose

If you dont have any of the above please type N/A do not leave blank as the form wont submit.

1.Diagnosis *

2. Allergies *

3. Additional Medical information *

4. List Medications and Purpose *

Additional information

Smoker

Do you have pets if so please list them

Nearest cross street

Key Locks and lock box codes

Reports and Plans

Is there a behaviour support plan in place if so please provide a copy *

Yes No

Are there any restrictive practices in place *

yes no

Behaviour support plan

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Does the Participant have a mealtime management plan from a therapist/ or oral dysphasia plan or modifications to their mealtime including allergies. *

Mealtime Managment plan

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Is there a functional Capacity Assessment or OT report

Do you consent to providing a copy

Yes No

We understand they are personal documents but can provide vital information to providers could you please explain why or provide a partial report relevant to your supports.

Functional Capacity assessment / OT report

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Any other relevant reports or letters

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Services Required

Services required:

example:

Lawn maintenance, Domestic support, meal prep, social support, community access, transport, Nursing services, personal care, STA, MTA, SIL, Medication management, 24/7 support, sleepovers, respite ect

Please list proposed times and days.

Services required please include requested days and times

SIGNATURE

I confirm that above information I have provided is true, complete and accurate.

Name

Client / Guardian Signature

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