Online Client Intake Form

MorethanDis

Menu

Home
About MorethaNDIS
- Our Purpose
- Our Vision and Values
Our Team
Our Services
Rates & Charges
Referral
Contact Us

Registered NDIS Provider

Client Intake Online Form

Participant Details (required)

First Name *

Last Name *

Sex : *MaleFemaleIntersex or indeterminatePrefer not to say

Are you an Aboriginal or Torres Strait Island descent? *YesNo

Preferred name : *

Date of birth: (dd-mm-yyyy) *

Residential Address Details (required)

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Participant Contact Details (required)

Email Address : *

Phone No : *

Alternate Phone No :

NDIS Information (required) :

NDIS Number : *

Plan review date (Must be reviewed annually) (dd-mm-yyyy):

NDIS Start Date (dd-mm-yyyy):

NDIS End Date (dd-mm-yyyy):

Funding Type : *Plan managedSelf - managedNDIA managedother

If plan managed Check box belowEnter details below

Provider name :

Email address :

Contact number :

Send invoices to :

Are you registered with another NDIS provider?YesNo

If yes, please specify the service you are receiving with the NDIS provider :

Advocate/representative details (if applicable)Enter details below

Given Name(s) :

Surname :

Relationship with the participant :

Phone No :

Mobile No :

Email :

Address Details :

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Other Information (required)

Country of birth : *

Number of years in Australia (if not born in Australia) :

The main language spoken at home : *

Is a language interpreter required? *YesNo

Are there any cultural, communication barriers or intimacy issues that need to be considered when delivering services? *YesNo

Verbal communication or spoken language - Is an interpreter needed?NoYes

Language

Cultural values/ beliefs or assumptions :

Cultural behaviours :

Written communication/literacy :

Physical Profile

Weight :

Height :

Eye Color :BrownHazelGreenBlue

What is your complexion ?FairLightOliveDark

What is your build ?SmallMediumLarge

Hair color ?BrownRedBlondeGreyBold

Facial Hair ?YesNo

Tattoos ?YesNo

Birth Marks ?YesNo

Emergency Details (Primary Contact) (required)

Contact Name : *

Relationship : *

Alternate Phone no :

Emergency Details (Secondary Contact)

Contact Name :

Relationship :

Alternate Phone no :

Specialist Medical Contact/Behaviour Support Practitioner (if applicable Click Yes)Yes

Do you see a specialist for a medical condition/disability?NoYes

Clinic Name :

Email Address :

First Name :

Surname :

Address :

Telephone Number :

Mobile Phone Number :

Living and support arrangements (required)

What is your current living arrangement? (Please tick the appropriate box) *Live with Parent/Family/Support PersonAged Care FacilityOwns own homeLive in private rental arrangement with othersHostel / SRS Private AccommodationLive in private rental arrangement aloneLives in public housingMental Health FacilityStaff Supported Group HomeShort Term Crisis/RespiteOther , please specify :

Travel

How do you travel to work or school or to your day service? (Please tick the appropriate box)TaxiPick up/ drop off by Parent/Family/Support PersonTransport provided by a provideIndependently use Public TransportWalkAssisted Public TransportDrive own carOther , please specify :

Disability Conditions/Disability type(s)

Indicate what type of disability or disabilities this participant has including diagnosis eg: ADHD

Are there any important people in the participant’s life such as family member and their relationship?

Educational Placement (if applicable and attach relevant reports)

Does the participant currently attend school or kindergarten?NoYes

If yes, name of the school / kindergarten / work / education site?

If yes, does the participant receive support within their environment?NoYes

If yes, which type? (tick all that applies)ESLNEP / IEPGowrieEducational Support WorkerSpeechSpecial Education1!1 SSOClass SSOOTOther

Teacher's Name :

Class / Year / Level :

Main concerns within this setting (tick all that applies)CommunicatingPlaying with other kidsCompleting WorkSharing with other kidsChallenging BehavioursTransitionDisruptive BehavioursEngaging in group activitiesOther

Examples of what these concerns look like for the participant in these settings:

Services required

Which of the following services best applies to your requirements? (tick all that applies)Household TaskTherapeutic SupportEarly childhood supportCommunity ParticipationDevelopment - life skillsAssistance - travel / transportGroup / centre activitiesAssistance - personal activitiesInnovative Community ParticipationAssistance - High intensity personal activitiesDaily Tasks / Shared LivingBehaviour SupportOther support :

Availability for behaviour support services (this gives us an idea when scheduling therapy hours)

Sessions (2-3h per session) *Morning 08:30 am to 11:30amLunch 12:00 noon to 02:30pmAfternoon 03:30pm to 05:30pm

Date *

Day

Month

Year

PLAY AND LEISURE ACTIVITIES

Participant’s likes and interests

What does the participant play with / enjoy doing / how does the participant entertain themselves? For how long?

Behaviour of concern (if applicable)

Does the participant engage in any behaviours of concern? If yes, please elaborate. If no, please skip to the next section.

Answers to the next questions relate to each other. Please respond as per their respective columns.

Top 3 most concerning behaviours

When are they most likely to happen

Describe if they occur around any specific activities

What triggers the behaviour

How do you and others react / respond to it to stop it?

How do you / others calm / distract the participant once they are engaging in it?

Name 3 of the participant’s strengths?

Medication Information/Diagnosis/Health Concerns (if applicable)

Does the participant require a Medication Chart?YesNo

Does the participant require Mealtime Management?YesNo

Does the participant require Bowel Care Management?YesNo

Is there any issues with a menstrual cycle or is assistance needed?YesNo

Does the participant require female hygiene assistance?YesNo

Does the participant have epilepsy?YesNo

Is the participant an asthmatic?YesNo

Does the participant have any allergies?YesNo

Is the participant anaphylactic?YesNo

Do you give permission for our company’s staff to administer band-aids in cases of a minor injury?YesNo

Does this participant require specific training?YesNo

Are there any other medication conditions that will be relevant to the care provided to this participant?YesNo

Is there any specific trigger for community activities?YesNo

Safety Considerations

Does the participant show signs or a history of unexpectedly leaving (absconding)?YesNo

Does the participant show any signs or a history of respiratory depression?YesNo

Is this participant prone to falls or have a history of falls?YesNo

Is there any behaviours of concern? Eg: kicking, biting.YesNo

Is there a current Positive Behavior Support Plan (PBS) in place?YesNo

Does the participant require communication assistance?YesNo

Is there any physical assistance or physical assistance preference for this participant?YesNo

Does the participant have any expressive language concerns?YesNo

Does this participant have any personal preferences & personal goals?YesNo

Search

About MorethaNDIS

MorethaNDIS offer therapy services by conducting functional behaviour assessments and developing evidence-based interventions to reduce challenging behaviours and replace them with functionally equivalent alternatives.

Our Purpose
Our Vision & Values
Our Team

Our Services

Positive Behaviour Support
Group Acceptance & Commitment Therapy
Positive Parenting Workshop
PD: Making it work for teachers
Rural/Regional Support
1:1 Acceptance & Commitment Therapy
Supported Independent Living (SIL)
Respite Care
Speech Therapy
Occupational therapist
Exercise Physiotherapist

Resources

Feedback & Complaints
Privacy Policy

Contact Us

Service Enquiry
Career
Feedback & Complaints

Say hi! on Social

Instagram

Disclaimer: MorethanDis Pty Ltd, acknowledges the Traditional Custodians on the lands throughout Australia. We pay our respects to Elders past, present and emerging and celebrate the diversity of Aboriginal peoples and their ongoing cultures and connections to the lands and waters of Australia.