Enquiry Form - Grace Care Collective

Grace Care Collective – Participant Intake Form

Participant Details

Client Full Name *

Date of Birth

Sex

Select

Male

Female

Non-binary

Prefer not to say

Country of Birth

Select

Australia

New Zealand

United Kingdom

Other

Aboriginal or Torres Strait Islander : Yes No

Main language spoken at home:

Parent / Guardian Details (if applicable)

Full Name

Phone

Email Address *

Address

City / Town

Select

Sydney

Melbourne

Brisbane

Perth

Adelaide

State / Region

Select

NSW

VIC

QLD

TAS

ACT

Postal / Zip Code

Country

Select Country

Australia

New Zealand

Other

Diagnosis

NDIS Number

Support Coordinator Name

Contact Details

Plan Start Date

Plan End Date

Funding Type : Self-Managed Plan-Managed NDIA-Managed

Plan Manager Name

Plan Manager Email

Plan Manager Phone

Available Budget for Therapy:

Therapy Service Information

Type of Therapy Service you are seeking : OT Speech Behavior Support

Type of Communication:

Do you require an interpreter : Yes No

Medical Details

Any other medical conditions:

Medications:

Any allergies:

Participant's medical practitioner name or other supports:

Behavior & safety Information

Is there a PBSP in place : Yes No

History of aggression or self-harm Absconding Sensory Triggers Communication challenges Mobility concerns

Home Visit Risk & Safety

Pets in the home : Yes No

Parking/access instructions:

Gate/door codes (if applicable):

Smoking in the home : Yes No

Domestic violence : Yes No

Child protection issues : Yes No

Risk to the client or visiting Staff : Yes No

Criminal history : Yes No

Anti-social behaviors : Yes No

Living arrangements:

Who will be present during sessions:

Where will services be conducted : Home School Preschool Community Telehealth

Name of school/ preschool/ relevant programs:

Reason for Referral

Main Concerns:

Strengths and Interests:

NDIS goals:

Therapy Frequency

Assessment only On-going weekly On-going fortnightly On-going monthly

Preferred Booking time : Morning Midday Afternoon

Consent & Communication

Consent to Collect & Share Info : Yes No (with relevant providers)

Privacy Acknowledgement : Yes No ( I understand that my information will be stored securely and used only for the purpose of providing therapy services)

Do you consent to receiving services via telehealth if required : Yes No

Preferred communication : Email Phone SMS

Emergency Contact (In case of emergency)

Name

Phone Number

Relationship

Name of person completing form

Relationship to participant

Signature :

Date