Phone:
1300031513
/
0459 901 972
/
0420 508 809
Email:
info@kedsolutions.com.au
| ABN: 35 405 606 974
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Assessment
Contact Us
Home
About Us
Our Services
About The NDIS
Assessment
Contact Us
Intake Assessment Form
Name
*
Gender
*
Please Select...
Male
Female
No Preference
DOB
*
MM slash DD slash YYYY
Funding Source
NDIS Number
*
ISP Number
Address
*
Contact number
*
E-mail address
*
Referred by
Supports needed
Coordination of support
Individual Supports
Details of support needed
How is your plan managed?
NDIA Managed
Self-Managed
Plan Managed (Details Below)
Plan Manager Details
Primary Diagnosis
Secondary Diagnosis
Likes
Dislikes
Hobbies
Communication
Verbal
Written
Compics
Other
Other
Mobility
Independent
Semi-Independent
Full Support
Mobility Aids in use
Wheelchair
Walking frame
Walking Cane
Vision Impairment
No
Yes
Please Describe
Hearing Impairment
No
Yes
Please Describe
Diabetic
No
Yes
Please Describe
Epileptic
No
Yes
Epilepsy management plan needed
Max. file size: 128 MB.
Continence Issues
No
Yes
Do any other people live with the participant?
No
Yes
Is there a current Behaviour Support Plan (BSP)?
No
Yes
Obtain a copy of the BSP
Max. file size: 128 MB.
Are you connected with a community mental health team?
No
Yes
Details
Does the participant have a guardian?
No
Substitute decision maker
Guardian
Public Guardian
Details
Details (paperwork needed)
Does the participant have a financial guardian?
No
Family or other
Financial Manager
Details (paperwork needed)
Details
Primary Carer Details
Name
Relationship
Address
Contact Number
Is this person the emergency contact person?
Yes
No
Secondary Carer Details
Name
Relationship
Address
Contact Number
Is the participant known to the police?
No
Yes
Details
Has the participant ever been supported by
Parole & Probation
Drug & Alcohol Services
Mental Health Services
None
Do you have any previous or current court orders?
No
Yes
Copy of court orders needed
Max. file size: 128 MB.
Is the participant currently being supported with any legal matters?
No
Yes
Details
Cultural Background/ Religious beliefs
No
Yes
Beliefs and Values consultation form needed
Max. file size: 128 MB.
Dietary requirements?
Known Allergies
Other important information
Staffing preferences
Preferred Gender
Male
Female
No Preference
Preferred Age
18 - 25
25 – 35
45 - 60
60 +
No Preference
Personal qualities
Specialist skills needed
Diabetes
PEG Feeding
Epilepsy Management
Other
Details
Completed By
Date
MM slash DD slash YYYY
