Download Client Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client Name *FirstLastClient Date of Birth:NDIS Number:NDIS Funding Type:Agency Managed (NDIS)Self ManagedPlan ManagedProvide Plan Manager (if applicable) see NDIS Funding TypeAddressContact NumberEmailPreferred method of contactPhoneEmailMailSMSRepresentative or Emergency Contact DetailsName *FirstLastRelationship to ClientAddressPhone NumberEmail *Preferred method of contactPhoneEmailMailSMSAbout youLiving SituationOwn home (alone)Own Home (with family)Supported AccommodationTemporaryOtherAboriginal or Torres Strait Islander descent?YesNoDoes the Client have a current Behavioural Support PlanYesNoPrimary Formal DiagnosisSecondary Formal DiagnosisDo you have any allergies? If yes please provide belowPlease provide all medical diagnoses and medicine that may affect the support providedPlease provide the name and contact number for Client's DoctorPlease disclose any legal issues that may affect service eg. Apprehended Violence OrderTypeVerbalNon-VerbalCommunication aids requiredOtherOther TypeOther TypeAre you of a culturally or linguistically diverse background?YesNoDetailsDo you have any culture, diversity, values and beliefs of which we should be aware?YesNoDetails (copy)Languages SpokenEnglishOtherDetails (copy) (copy)Is an Interpreter required?NoHearing ImpairedLanguageDo you consent to participating in and use of…Photos for Goal DataPhotos for Social MediaPhotos for the websiteParticipating in audits in respect of our business by the NDIS Commission andits auditorsYour personal information being recorded in audio and/or visual formatNone of the aboveDietary RequirementsI have the following allergies/intolerances and my favourite food is…No dietary requirementsYesNoVegetarianYesNoVeganYesNoI am allergic to (please list)I am unable to eat (sensory/intolerances)My favourite food is…HELPU Support Services can assist me during mealtimes by…I can identify what foods are safe for me to eat (if required due to allergy or dietary requirements).If I have a food allergy, I have provided HELPU Support Services with a management plan.If required I will bring any medications to assist me with my allergy and have completed the relevant medical formsI prefer to provide my own food and will do soMental HealthI have/experience…DepressionAnxietyPsychosisSchizophreniaBipolarOtherI would like HELPU Support Services to help me manage this by…My triggers may include…My triggers may include… (copI am supported/linked with the following organisations who assist me… (Please supply relevant management plans.)y)CheckboxesI have received medical support to assist me and HELPU Support Services has a copy of any relevant management plans to help me manage.Physical HealthI have…DiabetesSleep ApnoeaEpilepsyDietary NeedsAsthmaBlood DisordersVisual ImpairmentHearing ImpairmentCognitive ImpairmentHeart ConditionsOtherOtherAllergies to:I am on the following medications:List of medications:I would like HELPU Support Services to help me manage this by…Practical Support Needs Check the boxes which best represent you and your support needs… BehaviourTraffic awarenessI can do independentlyI need a little helpI cannot do independentlyStaying with the groupI can do independentlyI need a little helpI cannot do independentlyCommunicating appropriatelyI can do independentlyI need a little helpI cannot do independentlyBeing aware of personal spaceI can do independentlyI need a little helpI cannot do independentlyKeeping my hands to myselfI can do independentlyI need a little helpI cannot do independentlyTravelling safely in a carI can do independentlyI need a little helpI cannot do independentlyFollowing instructionsI can do independentlyI need a little helpI cannot do independentlySwimming and safety around waterI can do independentlyI need a little helpI cannot do independentlyI can handle my own spending moneyI can do independentlyI need a little helpI cannot do independentlyI am comfortable in my sleeping routineI can do independentlyI need a little helpI cannot do independentlySwimming and safety around water (copy) (copy) (copy)I can do independentlyI need a little helpI cannot do independentlySwimming and safety around water (copy) (copy) (copy) (copy)I can do independentlyI need a little helpI cannot do independentlyHELPU Support Services can assist me by…I have provided HELPU Support Services with any relevant behaviour plans for assisting me when required.I have provided HELPU Support Services with any relevant behaviour plans for assisting me when required.A bit about you and your goals To help us understand you better, please fill the below:💪 My strengths are (what I am good at)…👍 I like…I don’t like… (please include any sensory considerations)You will know when I am happy by…You will know when I am unhappy by…I prefer to communicate by…What are your goals for the next 12 months?How have these goals changed since your previous Support Plan (if applicable)How do your existing support from us or other providers help achieve desired outcomes? Is there any opportunity to use less intrusive options, in accordance with contemporary evidence-informed practices that meet participant needs and help achieve desired outcomes.Health requirementsActivityContinent with regular bowel and bladder actionConstipation, diarrhoea or incontinence (using medication, supplements, pads)Medical interventions (catheter, stoma bag)Outline condition, treatments, aids/assistance required, from whom and whenSkin IntegrityNo skin problemsSome skin problems (rash, skin treatments)Pressure areas (currently have, at risk, or had in past)Outline condition, treatments, aids/assistance required, from whom and whenSwallowingNo swallowing issuesSome swallowing problems (choking, coughing during normal meal, reduced appetite)Major swallowing difficulties (modified diet, feeding tube)Outline condition, treatments, aids/assistance required, from whom and whenHealth professionalsHave had a GP check up in the last 12 monthsSee a specialist regularlyHave a case manager/support coordinatorOutline condition, treatments, aids/assistance required, from whom and whenMuscular painNo painModerate painSevere painOutline condition, treatments, aids/assistance required, from whom and whenNerve painNo painModerate painSevere painOutline condition, treatments, aids/assistance required, from whom and whenFallsNo falls in past 12 monthsLess than 3 falls and no serious injury from a fall in past 12 monthsMore than 3 falls or a serious injury from a fall in the past yearOutline condition, treatments, aids/assistance required, from whom and whenMuscular issues (other than pain)No problemsSome muscle weakness, tremor, spasms, spasticity or problems with balanceSerious muscle weakness, tremor, spasticity or problems with balanceOutline condition, treatments, aids/assistance required, from whom and whenOther health concernsFatigueVisual disturbanceTemperature intoleranceOther comorbiditiesOutline condition, treatments, aids/assistance required, from whom and whenSocial RequirementsFamily:Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Hobbies & Interests:Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Religion & spirituality:Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Outings: E.g. theatre, cafes, exhibitions, drives, group activitiesOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Computer: E.g. games, shopping, education, bookingsOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Employment: Education, VolunteeringOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Sports:Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Music: Likes, dislikesOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Movies/TV: Likes, dislikesOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Well-being: E.g. exercise, gym, swimming, massage, yoga, meditation etc…Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Food and alcohol: Likes, dislikes, dietsOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Sex and intimacyOutline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Other:Outline how you want to do this activityProvide details of the activity, the time spent, the assistance required, from whom and when (including vouchers)Behavioural requirements IssueCommunicationNo assistance required (including independent use of aids and adaptive technology)Some assistance required (prompting, assistance with aids)Assistance always requiredOutline the issue, aids, assistance and management strategies requiredSubmit