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    Participant Details

    Participant Name:

    D.O.B:

    Gender:

    NDIS Number:

    Contact details(Home):

    Contact details(Mobile):

    Email address:

    Language spoken at home:

    Interpreter required:

    Preferred option for communication:

    Do you identify as Aboriginal and Torres Strait Islander?

    Residential Address:

    Postal Address (if different from above):

    Is there a Guardianship and/or Administration order in place?

    Is there a Behaviour Management Plan in place?

    * Participants under the age of 18, under guardianship or in the care of family or caregivers, please complete below

    Name of Parent/Guardian 1:

    Primary Carer

    Lives with Participant

    Emergency Contact

    Relationship to participant

    Email address

    Contact details(Home):

    Contact details(Mobile):

    Residential Address:

    Postal Address (if different from above):

    Name of Parent/Guardian 2:

    Primary Carer

    Lives with Participant

    Emergency Contact

    Relationship to participant

    Email address

    Contact details(Home):

    Contact details(Mobile):

    Residential Address:

    Postal Address (if different from above):

    Medication/s Required

    Medication Assessment Tool

    Strategies Developed

    Identified in Support Plan

    Medication Plan and Consent Form

    Medication – Self Medication Assessment

    Medication Risk Indemnity Form

    Disability / Medical Conditions including any diagnosis if relevant.

    Behaviour Support

    Behaviour Support Plan documents collected for authorisation purposes (if relevant)

    Behaviour Support Plan available on NDIS portal?

    * Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

    Name:

    Phone number:

    Email:

    Frequency of use:

    Address:

    Name:

    Phone number:

    Email:

    Frequency of use:

    Address:

    Health Care Information

    Medicare Number:

    Expiry Date:

    Reference Number:

    Private Healthcare Provider:

    Membership Number:

    Reference Number:

    Doctor Name:

    Phone Number:

    Address:

    Funding

    NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

    Phone Number:

    NDIS Date:

    Managed Funding Overview:

    Please provide details for invoices

    Name:

    Email:

    Comments:

    Preferences

    Preferred Name:

    Religious Requirements:

    Cultural Requirements:

    Communication Device:

    Physical Assistance:

    Other Considerations:

    Goals and Aspirations

    What do you want to achieve for yourself – life skills, physically, socially etc?

    Immediately

    In 6 months

    Next year

    Risk Assessment

    Risk Assessment Tool

    Strategies Developed

    Identified in Support Plan

    Individual Risk Assessment Profile

    Safety Environment Checklist – Home

    Participant Safe Environment Risk Assessment

    Nutrition and Swallowing Risk Checklist

    • This organisation owns these records.

    • Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties

    • I can ask to see records and receive a copy

    • Records are archived for a set period according to policy and procedure

    • I understand that all information obtained will be kept confidential.

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