Referral Intake Risk Assessment Tool Client’s Name Name of referrer if not client Relation and contact number of referrer Client’s Date of Birth Client’s NDIS Number Client’s Address Client’s Phone Number Intake Assessment Personal Details Who is the best contact for appointments? ClientOther Name Email Preferred method of contact PhoneEmail Relationship Participant Background Communication Needs/Supports Are there any communication/ behaviour supports in place or required? YesNo Please complete information regarding the participant including nature of disability, behaviour and support needs Cultural Identity CALD background? YesNo Aboriginal or Torres Strait Islander? YesNo LGBTQIA+ YesNo Interpreter required? YesNo Cultural considerations? YesNo Supported decision making/legal orders YesNo Does the client have an authorised person, guardian, or nominee in place? YesNo What decisions will they be involved in? Are there any current legal orders in place? Services Request Services client wishes to engage Primary goals for service Is this the client’s first NDIS plan? YesNo NDIS plan start date NDIS plan end date Is the support self, plan or agency managed? SelfPlanAgency If plan or self managed, where should invoices be sent Consent to share a copy of the NDIS plan with? YesNo Copy of NDIS plan provided? YesNo Is there a current Behaviour Support Plan in place? YesNo If yes, has a copy been provided? YesNo Safety Assessment General Are you aware of anything that would be a danger to a visiting worker at your residence? NoYes Housing Do you live with anyone? NoYes Relationship to you Are they ever violent or aggressive towards anyone? NoYes What type of housing do you live in? PrivatePublicSRS/Supported accomAged careOther Is the house number visible from the street? NoYes Hazards Do you have anything in your house that would make it unsafe for workers to visit? Do you own any animals? NoYes Are there any weapons on the property? NoYes Does anyone smoke on the premises? NoYes Is there any alcohol or drug use on the premises? NoYes Is there anything additional you would like to share relevant to services? NoYes Billing Consent Participant understands that we will bill from their NDIS plan at the rate specified in the latest NDIS Support catalogue? Participant consent to creating a service booking? Upload NDIS Plan
