Participant Details

Participant Name (Required)

Date Of Birth

Gender (Required) --Select Option--MaleFemaleother's

Contact details

Home (Required)

Mobile (Required)

Email address (Required)

Language spoken at home: (Required)

Interpreter required (Required)

Preferred option for communication

Email (Required)

Post

Phone (Required)

Do you identify as Aboriginal and Torres Strait Islander?
YesNo

Residential Address: (Required)

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

For participants under the age of 18 years of age, under guardianship or in the care of family or caregiver please complete below.

Name of Parent/Guardian 1

Primary Carer
YesNo

Lives with Participant
YesNo

Emergency Contact
YesNo

Relationship to participant
ParentGuardianCaregiverOther

Residential Address

Postal Address (if different from above)

Contact details

Home

Mobile

Email address

Name of Parent/Guardian 2

Primary Carer
YesNo

Lives with Participant
YesNo

Emergency Contact
YesNo

Relationship to participant
ParentGuardianCaregiverOther

Residential Address

Postal Address (if different from above)

Contact details

Home

Mobile

Email address

Disability / Medical Conditions including any diagnosis if relevant.

Other service providers currently using

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Name

Address

Phone number/email

Frequency of use

Health Care Information

Medicare Number

Expiry Date:

Reference Number

Membership Number

Reference Number

Doctor Name

Address

Phone Number

Funding

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

NDIS Number

NDIS Date

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

I understand that:
These records are owned by this organisation.
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.
To the best of my knowledge, the information provided in this form is true and correct:

Signature of Participant or Parent/Caregiver: