First Name:

Surname:

Phone Number:

Email:

NDIS Number:

Address:

Name of Referrer if not client:

Relation:

Information Regarding the participant including diagnosis, behaviour & Support Needs:

CALD Background:

Aboriginal or Torres Strait Islander:

LGBTQIA+:

Does the Client have an Authorised person,guardian or nominee in place:

If yes, who is this and what decisions will they be involved in:

Services Client wishes to engage in:

Primary Goals for Service or NDIS Goals:

NDIS Plan Start & End Date:

Is the Plan Self Managed or Plan Managed:

What email should the invoices be sent:

Are you aware of anything that would be a danger to a visiting worker at your residence:

Does the client live by themself or with others? If so, who?

Are they ever violent or aggressive towards anyone?

Does the client have anything in their house that would make it unsafe for workers to visit:?

Does the client have any weapons on the property?

Does the client own any animals?

Does the client smoke or drink?

Is there anything additional you would like to share relevant to services:

NDIS plan