Intake Inquiry - rahacommunitycare.com.au

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Referral Inquiry

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Intake Inquiry

Intake Inquiry

1. Participant Details

Name

D.O.B

Gender

Preferred name

Cultural background

Address

Postal Address (if different from above)

Mobile

Phone

Email

Language Spoken at Home

Interpreter RequiredYesNo

Preferred Option for CommunicationEmailPostPhone

Do you identify as Aboriginal and Torres Strait Islander?YesNo

NDIS Funding typeNDIS Managed (A copy of the NDIS plan MUST BE provided for NDIS managed participants)Self-ManagedPlan Managed

NDIS Number

NDIS start date

NDIS end date

Invoicing details

Name

Preferred option for communication

Phone number

Email

Address

2. Representative Details

Name of Representative

Lives with ParticipantYesNo

Relationship to participantParentGuardianCaregiverOther

Other (please specify)

Address

Phone

Email

Preferred method of contact

3. Emergency Contact Details

Is emergency contact the same as above?YesNo

Name of emergency contact

Lives with ParticipantYesNo

Relationship to participantParentGuardianCaregiverOther

Other (please specify)

Address

Phone

Email

Preferred method of contact

4. Health Care Information

Medicare Number

Expiry Date

Reference Number

Private Healthcare Provider

Membership number

Reference Number

5. About the Participant

Living situationLiving alone in my own homeLiving with my familySupported AccommodationTemporaryOther

Types of disability

Religious/ cultural requirements

Does the participant need physical assistance equipment or support

Does the participant need assistive devices for communication

Is the participant visually impaired

Does the participant have any dietary requirements

Does the participant have any swallowing difficulties

Other considerations

Does the participant have a current behavioural support plan?YesNo

If yes, please provide the details of your behaviour practitioner

Practitioner's name

Contact number

Address

Medical condition/diagnosis

Medical condition/diagnosis

Medical condition/diagnosis

Allergies

Please provide details of your medical practitioner

Name

Contact number

Address

6. Name of other current service providers

Service Provider 1

Name

Address

Phone number/email

Emergency contact

Frequency of use

Type of service

Service Provider 2

Name

Address

Phone number/email

Emergency contact

Frequency of use

Type of service

Service Provider 3

Name

Address

Phone number/email

Emergency contact

Frequency of use

Type of service

Service Provider 4

Name

Address

Phone number/email

Emergency contact

Frequency of use

Type of service

7. Goals

What do you want to achieve for yourself – life skills, physically, socially etc?

Short term goals

Long term goals

8. Consent

Please sign below to show that you agree with the information in this client intake form

Intake form was completed by

Participant Signature

Parent / caregiver signature

Name of the person signing

Relationship to the participant, if not the participant

Date

GET IN TOUCH

NDIS participant, family member, or support coordinator making a referral — our team is here to help. Start a no-pressure conversation today.

Ready to Get the Support You Deserve?

Office hours

Monday – Friday 9:00 AM – 21:00 PM

Book a Free Consultation

Raha Community Care is a registered NDIS provider and private nursing care service based in Melbourne’s eastern suburbs.

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Contact

0411 877 768
info@rahacaregroup.com.au
Head office: Ringwood, VIC 3134