NDIS Cleaning Intake – Yahweh Care Portal

1. NDIS Cleaning & Home Maintenance Intake Form:

Yahweh Property Care Use this form to collect information from NDIS participants or coordinators before preparing a quote.

Participant Name:

NDIS Number (optional):

Date of Birth:

Participant Address:

Suburb:

Postcode:

Phone Number:

Email Address:

2. Contact Person (if different):

Contact Name:

Relationship to Participant:

Phone Number:

Email Address:

3. Disability-Related Cleaning Requirement (NDIS Compliance) :

This request must be directly related to the participant’s disability and demonstrate how the disability impacts their ability to safely maintain their home environment. Please provide supporting information outlining how the participant’s functional limitations prevent them from completing cleaning tasks independently.

Reason cleaning support is required (tick all that apply):

Mobility impairments (e.g. difficulty bending, lifting, or standing)

Respiratory risks (e.g. dust, mould, chemicals affecting health)

Cognitive or psychosocial disability impacting ability to organise or safely complete cleaning tasks

OtherOther

Participant Explanation (required):

Please provide a brief explanation describing how the participant’s disability affects their ability to carry out cleaning tasks and maintain a safe and hygienic home environment:

Confirmation from the Support Coordinator:

Confirmation from the Support Coordinator: (Include details explaining whether the participant is approved for cleaning and why it is required)

4. NDIS Plan Information:

NDIS Funding Type:

Self-Managed

Plan-Managed

NDIS Managed

Plan Manager Name:

Plan Manager Email:

Support Coordinator Name:

Support Coordinator Email:

Plan start Date:

Finish Date:

Services Required (Tick all that apply):

NDIS - House Cleaning

NDIS - Yard Maintenance

NDIS - Pest Control

5. Home Details:

Home Type:

House

Apartment

Townhouse

Granny Flat

Living room:

1

2+

Number of Bathrooms:

1

2

3

4+

Kitchen Count:

1

2+

6. Cleaning Frequency:

Cleaning Frequency:

One-off

Weekly

Fortnightly

Monthly

Preferred Day:

Preferred Time:

Morning

Afternoon

Evening

7. Extra Tasks

8. Important Notes:

Mobility considerations / risks / allergies / pets / special instructions:

9. Quote Follow-Up:

Preferred Contact Method:

Phone

Email

SMS

When do you need the service to start?

Urgent

Within 1 week

Within 2–4 weeks

Flexible

Additional Message:

Supporting your preferences:

Do you have Specific Preferences?

• Communication Device

• Contact Method/Times

• Cultural/Religious

• Easy Read Documents

• Language (Written Spoken)

• Other

Please note:
• These records are owned by Yahweh Care.
• Information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties
• The participant can ask to see records and receive a copy
• Records are archived for a set period according to Yahweh Care policy and procedures
• All information obtained will be kept confidential.
• This information is used to set up the Service Agreement with Yahweh Care
• The Service Agreement is signed off by both the Applicant/Advocate, and Yahweh Care
• A signed Service Agreement is required to start Yahweh Care