Intake Form - MateCare

Client name: *

First

Last

NDIS Number: *

Date of Birth: *

NDIS Plan Start Date: *

NDIS Plan Finish Date: *

Plan Management Details *

NDIA-managed, Self-managed, or Plan Manager. (if applicable, please include plan manager details)

Registration Group Number *

e.g. 0107, 0125, 0115, 0117

Phone: *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

In case of emergency.

Nominee, Parent or Guardian's name: (If applicable)

First

Last

Relationship to client:

Phone

Email

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Client information

What are your interests?

Likes & Dislikes

What would you like to achieve through MateCare?

Please list all diagnoses, mental and physical that you have received from your doctor.

Does the participant have severe allergies/anaphylaxis?

Does the participant experience dysphagia and is there a current mealtime management plan in place?

Does the participant have any known emotional or behavioural conditions? If Yes, Please state briefly and discuss this with MateCare management.

Is the participant taking any medication, if Yes please give details.

Does the participant require assistance with the handling of their money?

Please list any restrictive practices currently implemented (if applicable)

Please complete the following to the best of your knowledge and discuss any specific concerns you have. This will enable us to support our participants to their individual needs.

Ability to be calm and peaceful at times.

Ability to deal with anxiety and stress.

Ability to express their feelings.

Self-esteem and self-confidence.

Ability to cope with feelings of anger

Ability to openly show care and concern for themselves and others

Attention span.

Ability to listen

Sleep pattern.

Specific concerns

Contact of the person making the referral, if different from the nominee or guardian details. *

Disclosure

I individually as a participant, nominee, parent or guardian identified above hereby agree to the following: Participant Responsibilities: MateCare takes all reasonable care to ensure that its services are fun and safe. However, I understand that I will be engaging in a small amount of physical activity that may involve some risk of injury. I acknowledge I have been advised to consult with my physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my participation in MateCare services. In the event of emergency I agree to MateCare contacting Emergency Services. Participant protection. I confirm that I have fully disclosed to MateCare any and all conditions (whether physical, mental or behavioural or otherwise). I assume the above risks and accept responsibility for any injury incurred. I further discharge and hold harmless MateCare including its owners, officers & personnel from any liability arising from any injury incurred or property caused by my participation during service with MateCare if that injury is caused either by my fault; or by a third party unconnected with MateCare. The provision of services;or by events with MateCare, its owners, officers & personnel could not have foreseen or prevented even if they had taken reasonable care.