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 PhoneEmailSMSFace to FaceTelehealth 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 Decision Making Supported decision making/legal orders YesNo Does the client have an authorised person, guardian, or nominee in place? YesNo Decision maker 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 Participant's personal preferences Likes Dislikes 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 Participant's Behaviour Supports Is there a current Behaviour Support Plan in place? YesNo If yes, has a copy been provided? YesNo Does the participant require a Functional Behaviour Assessment or Restrictive Practice Behaviour Support Plan regarding behaviours of concern? YesNo Does the participant display or engage in any behaviours of concern that require specific support? Does the participant have a current risk assessment relating to their behaviour or support needs? YesNo Current known strategies for supporting mental health or behaviour support (must be completed if BSP not in place with behaviours present) Community Participation Supports Does the participant need assistance getting around the community? What type of transport does the participant mainly use? Does the participant need assistance to use transport? Does the participant engage or participate in any recreational, community based, employment or training activities? Does the participant need assistance to access any of these activities? Details of other providers delivering supports and services, such as day programs or SIL arrangements. Any other information you would like to provide Emergency Information Emergency Contact Details Does the participant require assistance in an emergency? YesNo Does the participant have a Personal Emergency Alarm? YesNo GP Details Full Name Practice Phone Number Email Medication Medication Required YesNo Provide details of participant's Medication: Prompt Required YesNo Assistance Required YesNo Administration Required YesNo Please Give Details COVID-19 Vaccination Status Full Vaccination Booster of 3 doses2 doses of a COVID-19 vaccine1 dose of a COVID-19 vaccineHas not received a COVID-19 vaccineParticipant is exempt due to medical reasons Does the participant have a health or mental health care plan? YesNo Is the participant currently receiving end of life care/have an End of Life Care Plan? YesNo Does the participant have a signed DNR Order in place? YesNo Disability Supports Mobility Needs assistanceDoes not need assistanceIs independentIs not independent Details and Aids used Hearing Nil issuesSome issuesHearing impaired Details and Aids used Vision Nil issuesSome issuesVision impaired Details and Aids used Memory/Cognition Nil issuesSome issuesVision impaired Details and Aids used Communication Needs assistanceDoes not need assistance How does the participant prefer to communicate? VerballyNon-verbal/vocaliseSign languageAuslanMakatonKey Word SignPoint/gestureAugmentative and Alternative Communication (AAC) Details and Aids used Continence Needs assistanceDoes not need assistance Details and Aids used Daily Living Supports Showering/Bathing No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Grooming No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Dressing No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Toileting No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Eating No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Transfers (mobility) No help requiredAids usedPrompting requiredSome support requiredFull physical support required Details Day and Night Supports How often does the participant require supervision or support throughout the day? None of the timeAll of the timeDuring active times (e.g. getting ready, eating meals, going out, etc.) Details How often does the participant require supervision or support throughout the night? None of the timeAll of the timeDuring active times (e.g. toileting, transfers, behaviours, etc.) Details 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 Health and Medical Information AllergiesDisabilityDiagnosisMedical Conditions Disability, Diagnosis or Medical Condition Allergies Details Primary goals for service Information about the use of any mobility or communication aids, medical devices and other personal care items such as continence aids or wound 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
