NEW PARTICIPANTS · INTAKE Participant intake form Everything our intake nurse needs to plan safe support from the first shift. Sent securely to our intake team, who will call you within one business day. Before you start. This form takes about 15 minutes. You can complete it yourself, or a family member, guardian, support coordinator or hospital social worker can complete it on your behalf. Only the fields marked * are required; everything else helps us plan well but can be filled in later with your intake nurse. If you would rather do this over the phone, call (08) 9515 8000 any time and we will take the details with you. Who is completing this form? Your name * Your relationship to the participant *I am the participantParentGuardianFamily member or carerSupport coordinatorPlan managerHospital social worker or discharge plannerOther Your phone * Your email * Organisation (if applicable) 1. Participant details Participant's full name * Preferred name Date of birth * Gender—Please choose an option—FemaleMaleNon-binaryPrefer to self-describePrefer not to say NDIS number * Preferred contact methodPhoneEmailPostThrough my representative Home phone Mobile Email address Residential address * Postal address (if different) Language spoken at home Interpreter required?YesNo Do you identify as Aboriginal and/or Torres Strait Islander?YesNoPrefer not to say Is there a Guardianship and/or Administration order in place?YesNoUnsure Is there a Behaviour Support Plan in place?YesNoUnsure 2. Parents, guardians and representatives Complete for participants under 18, under guardianship, or where someone else is the main contact. Leave blank if it does not apply. Representative 1 Representative 2 Full name Relationship to participant —Please choose an option—ParentGuardianCaregiverPartnerSiblingOther —Please choose an option—ParentGuardianCaregiverPartnerSiblingOther Primary carer? YesNo YesNo Lives with participant? YesNo YesNo Emergency contact? YesNo YesNo Mobile Home phone Email Residential address Postal address (if different) 3. Disability, health and medication Disability and medical conditions, including diagnoses * Allergies and adverse reactions (medications, food, latex, other) Current medications (name, dose, how often, how taken) Tick any clinical supports the participant currently needs. This helps us roster the right nurse and workers from day one. PEG / enteral feedingTracheostomyVentilation (invasive or non-invasive)OxygenSeizure managementDiabetes management (insulin)Complex wound careUrinary catheterContinence assessmentBowel careSubcutaneous injectionsDysphagia / modified mealsPressure injury preventionMental health supportNone of these Mobility and transfers (equipment, hoist, number of workers) Communication (device, method, what works best) Medication documents Tell us what is already in place from a previous provider or clinician. We will complete whatever is missing during intake. Document Already in place? Identified in support plan? Medication Plan and Consent Form YesNoUnsure YesNoUnsure Self-Medication Assessment YesNoUnsure YesNoUnsure Medication Risk Indemnity Form YesNoUnsure YesNoUnsure Behaviour support Behaviour Support Plan documents available for authorisation?YesNoNot applicable Behaviour Support Plan lodged on the NDIS portal?YesNoUnsure Specialist Behaviour Support Provider (name and contact) 4. Health care information GP / doctor's name GP phone GP address / practice Medicare number Medicare reference number (the number beside the participant's name) Private health fund Membership number Other service providers currently involved Include allied health, behaviour support, other support providers and any hospital team involved in a current discharge. Provider name Service they provide Phone / email How often 5. NDIS plan and funding How is the plan managed? *NDIA managedPlan managedSelf-managedNot sure Plan dates (start and end) Support coordinator (name, organisation, phone, email) Plan manager or invoicing contact (name, organisation, email) Supports you are asking us for *24-hour complex care at homeHigh-intensity daily personal activitiesCommunity nursingSupported independent living (SIL)Respite / short-term accommodationHospital discharge and transition homeCommunity accessNot sure yet — please advise Roughly how many hours per week, and when? (e.g. active overnight, mornings, 2:1 shifts) Upload the NDIS plan (PDF or image, up to 10 MB). Required for NDIA-managed participants. Upload any other documents (discharge summary, care plan, mealtime plan, behaviour support plan) 6. Preferences Religious requirements Cultural requirements Worker preferences (gender, language, continuity) Physical assistance needed day to day Home environment we should know about (pets, smoking, parking, access, other people in the home) Anything else that helps us get it right 7. Goals and aspirations What do you want to achieve — life skills, health, getting out, relationships, independence? Your words, not NDIS words. Right now In 6 months Next year 8. Risk assessments already completed If a previous provider or hospital has completed any of these, tell us so we can request a copy rather than start again. Assessment Already completed? Identified in support plan? Individual Risk Assessment Profile YesNoUnsure YesNoUnsure Safety Environment Checklist – Home YesNoUnsure YesNoUnsure Participant Safe Environment Risk Assessment YesNoUnsure YesNoUnsure Nutrition and Swallowing Risk Checklist YesNoUnsure YesNoUnsure 9. Consent and declaration I understand that: Complex Care Continuum owns these records and keeps them securely, as described in our Privacy Policy. Information in these records is shared only with staff who need it to support the participant, and with the NDIS bodies, health professionals and representatives described in the Privacy Policy. The participant (or their authorised representative) can ask to see the records and receive a copy, and can ask for corrections. Records are kept for the period required by the NDIS rules and then securely destroyed. If the person completing this form is not the participant, an Authority to Act as an Advocate form will also be required. I consent to Complex Care Continuum collecting and using this information, including health information, to plan and deliver supports, as set out in the Privacy Policy. * I consent to Complex Care Continuum contacting the people and providers named in this form about the participant's supports. * To the best of my knowledge, the information in this form is true and correct. * Full name of the person signing (typed name acts as your signature) * Relationship to the participant, if not the participant Date * Your information is sent to our intake team over an encrypted connection. We will call you within one business day to confirm receipt and book your intake visit.
