Intake Form
Mildura Disability Support Services - ABN 61 684 083 574

Is this intake form for support coordination or disability support services? *

Disability SupportSupport CoordinationBoth Support Coordination & Disability Support

First Name *

Last Name *

Date of Birth *

Participant Phone Number *

Participant E-mail *

NDIS Number *

Participant Gender *

MaleFemale

Participant Address *

Street address *

City *

State *

Postcode *

Communication Type *

VerbalNon-VerbalCommunication aid requiredOther

Please specify

Country of Birth

Is the participant Aboriginal or Torres Strait Islander descent?

YesNo

Preferred method of communication is

PhoneSMSEmailMail

Please specify

Please provide details

Do you have a current Behavioural Support Plan? *

YesNo

Upload Current Behavioural Support Plan if applicable

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Participant occupation if applicable?

Are there any cultural considerations we need to be made aware of?

Are there any legal issues that may affect our service? If applicable, please provide details

Any other relevant information?

Preferred contact person? *

Advocacy form supplied? *

YesNo

Emergency contact - name *(if an emergency contact has already been listed above, please list a second here)

Emergency contact relation to participant *

Emergency Contact- phone number *

Emergency contact - email

Participant primary disability? *

Other medical conditions (if any)?

If the Participant suffers from asthma, epilepsy, diabetes, or anaphylaxis, please upload a copy of the emergency management plan

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For payment of MDS invoices, is the client's plan self or plan managed? *

Plan ManagedSelf ManagedNDIA Managed

What is the name of the Plan Manager & email address?

NDIS Plan Start Date

NDIS Plan End Date

Please upload a copy of the current NDIS plan or screenshot of participant NDIS Goals

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Which funding is the supports being billed from?Eg Core or Capacity Building. If unknown, leave blank.

Supported independent living/Respite Care/Group

Assistance with Daily Life Tasks in a Group or Shared Living ArrangementGroup and Centre Based Activities

Mildura Disability Support Services can assist me by ….

Is the Participant taking any medication? If so, please state dosage and frequency. If none, type NA *

Are MDS required to give the Participant medication during their support time? *

YesNo

If yes, please complete a medication authority form below. Medication will also have to be signed in by support workers when handed to them.

I would like assistance with managing my medication by

Please provide details

Medications for mental health? Please list

History of hospital admission?

YesNo

Please provide further details

I would like assistance with managing this by

Allergies, please list

I do not like to eat

My favourite food is

Practical support needs: I require assistance with

Please specify

YOUR PREFERENCES

Do you have specific preferences when matching staff?*

FemalesMalesNopreferences

Worker Age Group Preference *

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?

If medication is required to be administered by Mildura Disability Support, please complete a medication authority form here: https://form.jotform.com/243256824968066

Please note, we are unable to give medication if the form has not been completed.

What does the Participant like to do? List interests/hobbies/things they do for fun? *

Support Coordinator's Name (if applicable)

Support Coordinator Company, Phone number & email address (if applicable)

What NDIS funded service/s days & times are you requesting through Mildura Disability Support Services? Please included days, times and types of supports.

Day

TimesEg: 3.15pm to 6.15pm

Instructions or Activities?Eg: Pick up from day school & take to gymnastics

What is the service start date? *

Reason for Referral? *

Current services being received by the Participant eg OT, Physio, Psychologist behaviour, speech etc. If so please upload any relevant reports (eg Functional Capacity report) that will help us better manage the Participant.

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Please list any risks issues we need to know that might pose a risk to the staff or the Participant *(For example: aggressive/violent behaviour, absconding, IVO's, Court Orders, drug/alcohol issues, animals at the property)

CONSENT AND ACKNOWLEDGEMENT

By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.

Do you consent to participating in and use of *

Participating in audits of our business by the NDIS Commission and its auditorsPhotos for Social MediaPhotos for our websiteNone of the above

Person Completing the Form *

Signature *

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Date