First Gen Intake Form

Participant Details

Full Name:

First Last

Pronouns:

Date of Birth:

Home Address:

Address City State Post Code

Phone Number:

Email Address:

Preferred Communication Method:

Are they Aboriginal or Torres Strait Islander?

Which country were they born in?

Do they need an interpreter to help understand people who speak English?

Which language/s do they speak at home?

Are there ways we can include their culture in OT?

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Are you completing this form for yourself or on behalf of a relative?

Funding Type:

Referrer Details

Name:

First Last

Relationship:

Organisation:

Phone:

Email:

Reason for the referral?

What are the latest time frames needing any reports by?

Goals

List which goals to work on with an OT.

Goal 1:

Goal 2:

Goal 3:

Current phase of Care at Thomas Embling Hospital

Which unit are they in?

When in their release date?

Discharge destination anticipated / is there a discharge coordination contact point?

Best contact person at the Thomas Embling Hospital, eg the occupational therapist on unit?

First Last

Relationship:

Are we able to share any important information with this person?

Contact number:

Email address:

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Are there family members or informal supports?

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Name:

First Last

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Relationship:

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Are we able to share any important information with this person?

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Contact number:

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Email address:

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Is there anything important we may need to know before contacting this person?

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Are there other family members or informal supports?

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Name:

First Last

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Relationship:

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Are we able to share any important information with this person?

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Contact number:

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Email address:

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Is there anything important we may need to know before contacting this person?

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Who is the NDIS Support Coordinator?

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Name:

First Last

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Organisation:

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Are we able to share any important information with this person?

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Contact Number:

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Email Address:

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Who is the GP (General Practitioner)?

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Name:

First Last

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Organisation:

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Are we able to share any important information with this person?

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Contact Number:

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Email Address:

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Is there a professional in the support network?

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Name:

First Last

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Specialty:

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Organisation:

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Are we able to share any important information with this person?

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Contact Number:

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Email Address:

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Are there any other professionals in the support network?

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Name:

First Last

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Specialty:

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Organisation:

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Are we able to share any important information with this person?

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Contact Number:

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Email Address:

Disability and Health

What is the main health condition or disability?

Are there other health conditions or disabilities?

Which disability or disabilities are registered with the NDIS?

Are there any allergies?

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Life Overview

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Tell us a bit about your family:

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Tell us a bit about where you live and the people you live with:

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Are you studying or working?

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Are there any things that have happened in your life that may be important for the OT to know?

Regulatory Overview

Is there involvement with Child Protection?

Describe:

Are there any Court Orders?

Describe:

Are there any Community Interventions?

Describe:

Is there any involvement in the Justice System?

Describe:

Risk Considerations

Are there issues with assault or aggression, past or present?

Describe:

Are there any sexualised behaviours, past or present?

Describe:

Is there any substance use, past or present?

Describe:

Is there any self-injury or suicidality, past or present?

Describe:

Are there any home visit risks?

Describe:

Are there any behaviours of concern?

Describe:

Funding Overview

Participant/Claim Number

Plan Start Date

Plan End Date

Total amount allocated to Allay

Payment Method

Email or Plan Manager for invoices:

Please attach any plans or past reports

Drop files here or

Max. file size: 100 MB.

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Reporting

Any reporting will be finalised before the end of the NDIS Plan year and will be emailed to the NDIS.

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Email address to send report to:

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Due date for the report: