PARTICIPANT DETAILS
First Name
Last Name
Date Of Birth
Address
Suburb
Postcode
State
Contact Number
Email
Prefer Method of Communication
NDIS Number
NDIS Funding Type
Self Managed
Plan Managed
NDIA Managed
If applicable, Plan Manager/Plan nominee details:
Name
Organisation
Email
Contact Number
Plan start date
Plan end date
PERSONAL DETAILS
Aboriginal or Torres Strait Islander descent?
Living Situation
Own home (living alone)
Own home (living with family)
Living in supported accommodation
Temporary (relatives, friends or other)
At risk
Homeless
Other
Do you have a current Behavioural Support Plan?
Primary Formal Diagnosis:
Secondary Formal Diagnosis:
Are there any legal issues that may affect our service? If applicable, please provide details
Other relevant information:
REPRESENTATIVE OR EMERGENCY CONTACT DETAILS
CONTACT 1:
Advocate
Guardian
Emergency Contact
Support Person
Plan Nominee
Other
CONTACT 2:
Advocate
Guardian
Emergency Contact
Support Person
Plan Nominee
Other
Name
Name
Relationship to Client
Relationship to Client
Address
Address
Contact Number
Contact Number
Email
Email
COMMUNICATION
Type
Verbal
Non-verbal
Communication aids required
Others
Is an Interpreter required?
No
Langauge
Hearing impaired
PHYSICAL HEALTH
Medications (If applicable, please list)
I would like assistance with managing this by:
MENTAL HEALTH
Medications (If applicable, please list)
History of hospital admission
I would like assistance with managing this by:
DIETARY REQUIREMENTS
Allergies (If applicable, please list)
I do not like to eat: (please list)
My favorite food is:
PRACTICAL SUPPORT NEEDS
I require assistance with:
What St Anastasia’s Care services do you require?
1. Daily personal Activities
2. Assistance with Travel/Transport Arrangements
3. Innovative Community Participation
4. Development of Daily Living and Life Skills
5. Household Tasks
6. Participation in Community, Social and Civic Activities
7. Assistance with Daily Life Tasks in a Group or Shared Living Arrangement
8. Group and Centre Based Activities
St Anastasia’s Care can assist me by ….
YOUR PREFERENCES
Do you have specific preferences when matching our staff with you?:
Age Group
Culture/Religion/Ethnicity
Languages spoken
Personality characteristics
Specific needs, skills or knowledge required?
Specific training that may be required to provide services and support to you?
Is there anything else you would like us to know about you that is important for how we provide our services to you?
What are your goals, expectations and desired outcomes when receiving our services?
What are your goals for the next 12 months?
CONSENT AND ACKNOWLEDGEMENT
Do you consent to participating in and use of:
Date
SUBMIT
