Participant Intake Form – Yahweh Care Portal

1. Participant Details:

Participant Name:

Preferred Name:

Phone:

Email:

Date of Birth:

Residential Address:

Postal Address: (if different)

Language at home other than English:

Interpreter required?

Yes

No

Preferred Option for Communication:

Email

Post

Phone

OtherOther

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

Copy supplied:

Yes

Action required

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. Services Required, Preferred Days/Times and Support Ratio:

Requested service start date:

Urgency:

Preferred times per day

Start Time:

Finish Time:

Total hours per day:

Overnight / sleepover / active night support:

Transport required?

Yes

No

Pick-up address

3. Nominated Support Person :

Nominated Support Person: 1

Name:

Relationship to Participant:

Residential Address:

Postal Address (if different):

Home Phone:

Mobile:

Email

Advocacy Form Supplied?

Yes

Action Required

Nominated Support Person: 2

Name:

Relationship to Participant:

Residential Address:

Postal Address (if different):

Home Phone:

Mobile:

Email:

Advocacy Form Supplied?

Yes

Action Required

4. 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.

Does participant require Care Support Plan Management?

Yes

No

To be assessed

5. Funding and NDIS Information:

Funding

Medicare

NDIS

New Participant

OtherOther

Current funding arrangement for Professional Services?

NDIS Plan Start Date:

NDIS Plan End Date:

NDIS Number:

Plan management:

NDIA managed

Plan managed

Self managed

Combination

Plan manager Name:

Plan manager Email:

Support coordinator Name:

Support coordinator Email:

6. Residential, Home Environment and Access Information:

Smoking / environmental risks:

Pets at residence:

Yes

No

If Yes, details:

Key / entry arrangements:

Residential / access notes:

7. Health, Disability and Daily Support Needs:

Primary disability / diagnosis:

Secondary conditions:

Eating and drinking:

Independent

Prompting

Assistance

Mealtime plan attached

Personal care:

Independent

Prompting

Partial assistance

Full assistance

Toileting / continence:

Independent

Prompting

Assistance

Continence plan

Medication:

No support required

Prompting

Assistance

Medication chart attached

Allergies:

None known

Yes

If Yes, details:

Additional care support notes:

8. Risk Screening and Safety

Behaviour risks:

Behaviour support plan:

Not applicable

Attached

Required

Restrictive practices

Restrictive practices:

Yes

No

Manual handling assessment required?

Yes

No

To be assessed

Risk assessment required before commencement?

Yes

No

To be completed by Yahweh Care

Risk management actions / controls:

9. Consent, Records and Information Sharing:

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Consent to collect and store personal information for service delivery

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Consent to share information with relevant Yahweh Care staff where required to carry out duties

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Consent to contact emergency contacts, nominees, advocates and professional supports

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Consent to contact NDIS, plan manager and support coordinator for service setup and billing

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Consent to seek medical assistance in an emergency

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Consent for transport/community access where included in the service agreement

10. Documents Checklist:

11. 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

12. How did you hear about Yahweh Care?

Social Worker/Case Manager

Support coordinator

Other Yahweh Care client

Google / website

Hospital / discharge team

Social media

OtherOther

13. Participant / Representative Declaration:

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I confirm that the information provided in this intake form is true and complete to the best of my knowledge. I understand Yahweh Care may request further information or complete additional assessments before services commence to ensure supports can be delivered safely and appropriately.ration

Relationship / authority:

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Participant

Representative / advocate

Participant name:

Participant signature:

Clear

Representative / advocate name:

Representative signature:

Clear