Yahweh Care
Activity Log
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Participant Intake Form
Participant Support Plan
E-Signature Consent Form
Risk Assessment
Service Delivery Team Log
Client Signature Log
Participant Intake Form
Participant Intake Form
1. Participant Details:
Participant Name:
Preferred Name:
Phone:
Email
Residential Address:
Postal Address: (if different)
Language at home other than English:
Interpreter required?
Yes
No
Preferred Option for Communication:
Email
Post
Phone
Other
Other
Do you identify as Aboriginal and Torres Strait Islander?
Yes
No
Primary Disability:
Is there a Family member or Advocate to support the Participant
Yes
No
Is there a Guardianship and/or Administration order in place?
Yes
No
(If yes, please write the detail below)
If yes, please write the details below:
NOTE:
For participants under the age of 18 years of age or under guardianship or in the care of family or caregivers, please complete below.
2. Nominated Support Person :
Nominated Support Person: 1
Advocate
Parent
Guardian
Support Person
Emergency Contact
Plan Nominee
Child Representative
Other
Other
Name:
Relationship to Participant:
Residential Address:
Postal Address (if different):
Home Phone:
Mobile:
Email
Advocacy Form Supplied?
Yes
Action Required
Nominated Support Person: 2
Advocate
Parent
Guardian
Support Person
Emergency Contact
Plan Nominee
Child Representative
Other
Other
Name:
Relationship to Participant:
Residential Address:
Postal Address (if different):
Home Phone:
Mobile:
Email:
Advocacy Form Supplied?
Yes
Action Required
Your Professional Support :
Health Professional 1
Name:
Organisation:
Business Phone:
Mobile:
Email:
Health Professional 2
Name:
Organisation:
Business Phone:
Mobile:
Email
Care Plan Support:
Yes
No
Does the participant require Care Support Plan Management.
Funding
Medicare
NDIS
New Participant
Other
Other
Current funding arrangement for Professional Services?
How did you hear about Yahweh Care?
Friend
Your Professional Support Person
Other CCS client
New Option
NDIS Number:
NDIS Plan Start Date:
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
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