Participant Details Participant First Name * Participant Last Name * Date of Birth * NDIS Number * Participant Phone Participant Email Full Residential Address * Primary Contact Primary Contact Name * Relationship to Participant * Please selectParticipantParentGuardianPlan NomineeSupport CoordinatorOther Primary Contact Phone * Primary Contact Email * Who completed this intake? Please selectParticipantParent / GuardianPlan NomineeSupport CoordinatorReferrer / Other ProfessionalSCS AdminOther Service Required Which service/s are required? * Support CoordinationSpecialist Support CoordinationPsychosocial Recovery CoachingSupport Work / Daily LivingKey Work / Early ChildhoodOccupational TherapySpeech PathologyBehaviour SupportSupported Independent Living (SIL)Short Term Accommodation (STA)Medium Term Accommodation (MTA)Other If Other, please specify Please tell us briefly what support is required * NDIS & Billing Information How is the participant's NDIS funding managed? * Self ManagedPlan ManagedNDIA / Agency ManagedCombinationUnsure NDIS Plan Start Date NDIS Plan End Date Billing Details Please complete the relevant billing information below. The billing email may be the same as the participant or primary contact email above. Billing Contact Name * Billing / Invoice Email * Billing Contact Phone Plan Manager Details – if applicable Plan Management Organisation Plan Manager / Contact Name Plan Manager Phone Plan Manager Billing Email Any additional billing or funding information Participant Support Profile Primary Disability / Diagnosis * Other Diagnoses, Medical Conditions or Mental Health Information Communication VerbalLimited VerbalNon-SpeakingAAC / Communication DeviceAuslan / SignPictures / Communication BoardGesturesOther Communication Details or Important Instructions Preferred Language Interpreter Required? YesNo Cultural, Religious or Personal Considerations Participant's Primary Goals for Service Daily Living & Disability Supports Complete the areas relevant to the participant. Select Not Applicable where support is not required. Mobility Please selectIndependentPrompting / SupervisionSome AssistanceFull AssistanceNot Applicable Showering / Bathing Please selectIndependentPromptingSome AssistanceFull AssistanceNot Applicable Grooming / Dressing Please selectIndependentPromptingSome AssistanceFull AssistanceNot Applicable Toileting / Continence Please selectIndependentPromptingSome AssistanceFull AssistanceNot Applicable Eating / Drinking Please selectIndependentPrompting / SupervisionSome AssistanceFull AssistanceNot Applicable Transfers Please selectIndependentPrompting / SupervisionSome AssistanceFull AssistanceNot Applicable Please provide any relevant daily living, mobility, personal care or equipment details Transport & Travel Requirements Please provide any relevant transport requirements Medication, Allergies & Health Does the participant take medication relevant to their support? YesNo Medication Details Medication Support Required Prompt / ReminderAssistanceAdministrationNo Medication Support Required Allergies / Intolerances Significant Health or Mealtime Information Behaviour & Safety Are there any behaviours, emotional regulation needs or safety risks we should know about? YesNo Please provide relevant details Is there a current Behaviour Support or Risk Management Plan? Please selectYesNoIn DevelopmentUnsure Are restrictive practices currently used or authorised? Please selectYesNoUnsure Home & Environmental Safety Are there any hazards or safety considerations for staff attending the participant's home? Emergency Information Emergency Contact Name * Relationship * Emergency Contact Phone * Emergency Contact Email GP Details GP / Doctor Name Practice / Clinic GP Phone GP Email Documents & Consent Upload NDIS Plan Upload Relevant Support Document This may include a Behaviour Support Plan, medication chart, medical/action plan, mealtime plan, manual handling plan or other relevant document. Billing Consent I confirm that the participant or authorised representative consents to Sunflower Community Supports claiming or invoicing for agreed supports delivered in accordance with the participant's Service Agreement and applicable NDIS pricing arrangements. I understand and agree to the billing information above. Declaration I confirm that the information provided is accurate to the best of my knowledge and that I am authorised to provide this information to Sunflower Community Supports for the purpose of assessing, planning and delivering services. Name of Person Completing Form * Relationship / Role * Date *
