ABOUT YOU (Referrer) * Please select what describes you best? Participant Family Member Local Area Coordinator Early Intervention Partner Parent Support Coordinator Plan Manager Other Name * First Name Last Name Email Phone (###) ### #### PARTICIPANTS DETAILS * First Name Last Name Participants Date of Birth: eg 07/01/1997 * dd-mmm-yyy To enter your date of birth eg: 7th of January 1997, type it as: 07-01-1997 MM DD YYYY Participants Email Participants Phone Number (###) ### #### Participants Address * Street address, suburb & postcode Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Female: she/her Male: he/him Non binary: they/them Prefer not to say Other Do You/ Does the participant Identify as Aboriginal or Torres Strait Islander? No Yes - Aboriginal Yes - Torres Strait Islander Yes - Aboriginal and Torres Strait Islander Living Arrangements * Alone Family/Partner Supported Accomodation Other Do you require an interpreter? Yes No Please indicate the Translator/interpreter or the communication aids required WHO IS THE PRIMARY CONTACT FOR THE FIRST APPOINTMENT? * Is the primary contact for the first appointment the same as the person entered above? If not, please add primary contact details below. Yes No Additional Contacts Please list the people that are authorised to receive/sign the service agreement and information regarding services. Note: If you are completing this form on the behalf of the participant, please seek approval from the participant prior to completing this section. If you are a support coordinator and have consent from the client to receive the service agreement please enter your details below. Note: Participants can withdraw this consent anytime by emailing info@goodritualsot.com.au First Name Last Name Additional Contact Email Additional Contact Phone (###) ### #### Relationship to the Participant Participant Parent Family Member / Next of Kin Support Coordinator Administrator Support Worker PRIMARY DISABILITY BACKGROUND * Please provide detail of the primary disability. NDIS DETAILS * NDIS Plan Number Plan Start Date * MM DD YYYY Plan End Date * MM DD YYYY SERVICES * Primary Allied Health Service Required Home Modifications Assistive Technology Functional Capacity Assessment Capacity Building Home and Living Assessment Please provide further detail on the Occupational Therapy services required. * FUNDING * NDIS Funding Please confirm the funding available or hours of service required for the allied health supports requested GOALS * Desired Outcomes/Goals Preferred Delivery of Services * You can select one or more options At home In the community Day program School Work Preferred Appointment Time, day of the week and time? BILLING * How is the plan funding managed? NDIA or Agency Managed Self-Managed Plan Managed Plan Management Details Email, phone, address etc SAFTEY & SUBMIT * Are there any Safety Risks we should be aware of? Risk of injury or harm to their person or others Homelessness Substance abuse Loss of placement e.g. school accommodation day service School or Service placement interruption temporary Criminal history Sexual Do not know None Other Participant behaviours * Physical aggression Verbal outburst Property damage Serious injurious behaviour Do not know None Other * Please acknowledge that you believe the information entered on this form is, to the best of your awareness, truthful and accurate. * Thank you!
