Participant Details

Date: Given Name: Surname: Preferred Gender / Pronoun: MaleFemaleIntersex or IndeterminateDo not wish to discloseOther If Other, please specify: Preferred Pronoun: Aboriginal or Torres Strait Islander descent? YesNo Preferred Name: Date of Birth:

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Residential Address

Number / Street: State: Postcode:

Postal Address

Number / Street: State: Postcode:

Contact Details

Email: Home Phone: Mobile No:

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NDIS Information

NDIS Number: Plan Review Date: NDIS Start Date: NDIS End Date: Funding Type: Self-ManagedPlan ManagedNDIA-ManagedCombinationOther Are you registered with another NDIS provider? YesNo

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Advocate / Representative (if applicable)

Surname: Given Name: Relationship with Participant: Phone: Mobile: Email: Address:

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Other Information

Country of Birth: Years in Australia: Main language spoken at home: Any cultural/communication/intimacy issues? YesNo

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Physical Profile

Weight (kg): Height (cm): Eye Colour: BrownHazelGreenBlue Build: SmallMediumLarge Facial Hair: YesNo Birth Marks: YesNo Tattoos: YesNo Hair Colour: BrownBlondeRedBlackGreyBald Complexion: FairLightOliveDark

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Emergency Contacts

Primary Contact

Name: Relationship: Home Phone: Mobile:

Secondary Contact

Name: Relationship: Home Phone: Mobile:

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GP & Support Coordination

Clinic Name: GP Name: Email: Address: Phone: Mobile: Support Coordinator: Phone:

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Living & Travel Arrangements

Current Living Arrangement: With FamilyPrivate Rental (with others)Private Rental (alone)Aged CareOwn HomeMental Health FacilityPublic HousingRespiteGroup HomeOther Travel to work/day service: TaxiPick up by familyProvided TransportPublic TransportWalkAssisted Public TransportOwn CarOther

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Disability & Support

Disability type/diagnosis: Important people in participant’s life:

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Medication & Health

Medication Chart required? YesNo Mealtime Management required? YesNo Bowel Care required? YesNo Menstrual cycle assistance needed? YesNo Female hygiene assistance required? YesNo Epilepsy? YesNo Asthmatic? YesNo Allergies? YesNo Anaphylactic? YesNo Band-aid permission (minor injuries)? YesNo Specific training required? YesNo Other relevant medical conditions? YesNo Triggers for community activities? YesNo

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Safety & Behaviour

History of absconding (leaving unexpectedly)? YesNo Respiratory depression history? YesNo Prone to falls? YesNo Behaviours of concern? YesNo Positive Behaviour Support Plan (PBS) in place? YesNo Communication assistance required? YesNo Physical assistance required? YesNo Expressive language concerns? YesNo Personal preferences or goals? YesNo

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Signatures

Signature of Participant: Date: Signature of Nominee (if applicable): Date: Organization Representative: Organization Name: Date: