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Participant Intake Form

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Who's filling out the form? *

Participant
Authorised Representative
Support Coordinator
Local Area Coordinator
Allied Health Professional
Other

Relationship to the participant *

If "Other" is selected on the first option

What type of Services does the participant require? *

Community Participation
Household Tasks
Nursing Services
Personal Care / Support Workers
Transport Assistance
Specialised Support Coordination
Home-Based Child Service
Skill Development and Training

How heavily will you be relying on this support? *

Rarely – I might use this support occasionally, but only when needed.
Sometimes – I would use this support periodically, but not consistently.
Frequently – I would use this support regularly, but still have other options.
Heavily – I would rely on this support for most of my needs.
Completely – This support would be essential, and I would depend on it fully.

Are you transferring from one provider to us? *

Yes
No

Does the participant currently receive support from another provider *

Yes
No

How many providers does the participant currently have?

Selected Value: 0

How often does the participant receive support? *

Daily/Weekly/Monthly

What type of support does the participant receive from that provider *

Community Access / Personal Care / Domestic Help

Personal Information (PARTICIPANT)

Full Name *

First

Last

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Date of Birth *

Gender *

Male
Female
Non-Binary
Transgender
Prefer not to say

Language Spoken *

Interpreter Required? *

Yes
No

Contact Information (PARTICIPANT)

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Email

Email

Confirm Email

CLIENT EMAIL ONLY - AUTHORISED USER MUST USE ANOTHER FIELD

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Postal Address *

Same as Residential Address
Different Address

Postal Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Preferred Contact *

Email
Phone
Post

Is the person fillng out the form the primary contact? *

Yes
No

THIS MUST BE SOMEONE WHO CAN DEAL ON BEHALF OF THE PARTICIPANT. PLEASE MARK "NO" IF THE PARTICIPANT COULDN'T UNDERSTAND OR COMMUNICATE WITHOUT ASSISTANCE

Primary Contact Information

Primary Contact Full Name *

First

Last

Primary Contact Information

Primary Contact Email *

Email

Confirm Email

Primary Contact Address *

Same as Participant
Other

Primary Contact Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Contact Phone *

Primary Contact Date of Birth

Authorised Representative

Is the Primary Contact also an Authorised Representative *

Yes
No
No, but I want to add one

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Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

NDIS Information

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NDIS Number *

NDIS End Date

NDIS Start Date

Plan Review Date

Funding *

NDIA Managed
Self Managed
Plan Managed

Invoice Notifications *

Email

Confirm Email

NDIS Plan Document Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload the Client/Participant's NDIS Plan if available.

Name of Plan Manager

This could be the company or the name of the individual

Diagnosis or Health Concerns *

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Doctor's Name

First

Last

Doctor's Phone

Doctor's Email

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Enter any non-confidential files relevant to the client. These can be diagnosis or any medical procedures required for us. Please refer to our NDIS Privacy Policy on our website if you need more information

Goals and Aspirations

What do you want to achieve for yourself? *

Life Skills, Physically, Socially, Etc...

How soon would you like to achieve this? *

Immediately
In 6 months
In a year

Tell us more

Other Infromation and Preferences

Country of Birth *

Preferred Name *

Religious Requirements *

Type N/A if none

Cultural Requirements *

Type N/A if none

Communication Considerations *

Type N/A if none

Living Arrangements *

Live with Paren/Family/Support Person
Private rental arrangement alone
Private renal arrangement with others
Aged Care Facility
Mental Health Facility
Public Housing
Short-Term Crisis/Respite
Staff Supported Group Home
Hotel/SRS Private Accommodation
Own home
Other

Please select multiple if client has to move to multiple locations

Preferred Support day *

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

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Preferred Support Start-time *

Preferred Support End-time *

Emergency Contact *

Primary Contact
Authorised Rep
Other

THIS MUST NOT BE THE SAME AS THE PARTICIPANT

Other Emergency Contact

Other Emergency Contact Name *

First

Last

Other Emergency Contact Phone *

Relatationship to client *

Parent
Sibling
Cousin
Aunt/Uncle
Guardian
Colleague
Friend
Partner
Other

Wrap Up

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Email *

Person filling out the form

Form completed by *

First

Last

Phone *

Signed Date

I understand that *

Information within these records will be shared with other staff within the organisation on and only when required to carry out duties
Records will be kept for archiving for a set period according to SpotOnCare policy and procedures
I understand that all information obtained will be kept confidential

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NDIS Services

Services
Forms
Resources and Guides

Quick Links

Feedback/Concerns
Cleaning Booking
Travel Booking

Useful Links

Policies Page
Careers
FAQs

SpotOnCare (22)

info@spotoncare.com.au

Contact Us - SpotOnCare - 03 7042 5300

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Get Support

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What is your name? *

First

Last

Tell us who you are *

NDIS Participant
Family Member
Support Coordinator
Other

Please provide your Email so we could contact you *

Email

Confirm Email

What about your phone number? *

How can we best assist with your situation? Please check all that applies *

Physical Disability
Mental Disability
Sensory Disabilities (Hearing, Visual)
Learning Disabilities
Chronic Health Conditions
Communication Disabilities

Tell us more about the help you need. *

Where did you hear about us? *

Google Search
Word of Mouth
Social Media (Facebook, LinkedIn, Instagram)

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Contact Us

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Name *

First

Last

Email *

Subject

Message

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Contact Us - SpotOnCare - 03 7042 5300

SpotOnCare (22)

info@spotoncare.com.au