Assured Care Solutions

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Client Intake Form

Assured Care Solutions

Home
About Us
Services
Careers
News
Contact

Client Intake & Profile Services under NDIS

08 8374 2444

Client Referral Details

First Name *

Surname *

Date of Birth

Month

Day

Year

Gender

Phone Number *

Street Address

Email Address *

Living Arrangements *AloneFamily/PartnerSupported AccommodationOther

Interpreter required?YesNo

Primary Language spoken:

Does the Client identify as Culturally & Linguistically Diverse (CALD)?YesNo

Does the client identify as Aboriginal or Torrens Strait Islander?YesNo

Guardianship/Alternative Contact

Is the client their own decision maker?YesNo

Are there Guardianship orders in place?YesNo

Guardianship Provisions:HealthAccomodationFinancialOther

Guardian Details:

Guardian First Name

Guardian Surname

Street Address

Email Address

Phone

Alternative Contact:

Alternative Contact First Name

Alternative Contact Surname

Email Address

Phone

Relationship to Client:

Primary Diagnosis/Health/Medical Conditions/Behaviours of Concern

Primary Diagnosis

Specialised Health Condition Required?

Medication Administration Required

Does the client have the ability to Self-Administer Medications?YesNo

Verbal Prompting RequiredYes

Will require full support of Administrating MedicationYes

Mobility:

Ambulant?AmbulantNon Ambulant

Provide details of any Aids required to support mobility:

Behaviour Concerns:

Are there any behaviours of concern? *YesNo

If yes, is there a Positive Behaviour Support Plan in place?YesNo

Is there a Positive Behaviour Support Practitioner in place?YesNo

Details:

Name/Phone Number & Email:

Restrictive Practices:

Are there any Restrictive Practices in Place? *YesNo

If yes, please provide details:

Has the Client undertaken a Functional Capacity Assessment?YesNo

NDIS Plan Details

NDIS Number:

Current NDIS Plan Start date:

Month

Day

Year

NDIS Plan End Date:

Month

Day

Year

How is the NDIS plan Managed?AgencySelf ManagedPlan Managed:

Is there Support Coordination involved? *YesNo

Provider details:

Name

Phone

Email Address

Client Referral Services Required

Service RequiredSIL/SDACommunityPlan ManagementSupport Coordination

Support Ratio Required:1:11:21:3

Overnight SupportPassiveActive

Do you have more than one other provider involved in your supports?NoYes

Are there any Pets in the home?NoYes

If yes, is this an approved Service Dog?YesNo

Supports - Preferred Times:Ongoing WeeklyFortnightlyMonthly

Supports RequiredPersonal CareCommunity Access

Will transport be required?YesNo

Please indicate your ideal start time for each day

MondayYes

Monday Start Time

Hours

Minutes

AM/PM

TuesdayYes

Tuesday Start Time

Hours

Minutes

AM/PM

WednesdayYes

Wednesday Start Time

Hours

Minutes

AM/PM

ThursdayYes

Thursday Start Time

Hours

Minutes

AM/PM

FridayYes

Friday Start Time

Hours

Minutes

AM/PM

SaturdayYes

Saturday Start Time

Hours

Minutes

AM/PM

SundayYes

Sunday Start Time

Hours

Minutes

AM/PM

Public Holiday Supports RequiredYesNo

Support Worker Preferences

Age Group:

Gender:

Common interests that you would like us to consider:

Other relevant information:

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Assured Care Solutions acknowledges the traditional owners of country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to their Elders and extend that respect to Aboriginal and Torres Straight Islanders today.

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Contact

enquiries@assuredcaresolutions.com.au
(08) 8374 2444
20 Rosslyn Street Mile End South SA 5031

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NDIS Provider Number
4050000547

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