Client Registration Form

Download Client Registration Form

Client Name *

Date of Birth:

Registration Number:

Type of NDIS Funding:

(NDIS)

Self Managed

Plan Managed

Specify Plan Manager (if applicable); refer to NDIS Funding Type

Address

Phone Number

Preferred Contact Method

Phone

Mail

SMS

Representative or Emergency Contact Information

Name *

Client Relationship

Address

Phone Number

Email *

Preferred Contact Preference

Phone

Mail

SMS

About you

Living Arrangements

Living Independently (Solo)

Living with Family in Own Home

Assisted Living Arrangements

Temporary

Other

Are you of Aboriginal or Torres Strait Islander descent?

Yes

Does the Client Currently Have a Behavioral Support Plan?

Yes

Main Formal Diagnosis

Secondary Formal Diagnosis

Do you have any allergies? If so, please specify below.

Please list all medical diagnoses and medications that may impact the support provided.

Please provide the name and contact number of the client's doctor.

Please disclose any legal issues that may impact the service, such as Apprehended Violence Orders.

Type

Verbal

Non-Verbal

Required Communication Aids

Other

Are you from a culturally or linguistically diverse background?

Yes

Is there any cultural diversity, values, or beliefs you'd like us to be aware of?

Yes

Languages Spoken

English

Other

Is an interpreter needed?

Deaf or Hard of Hearing

Language

Are you willing to participate in and consent to the use of...

Goal Data Photos

Social Media Photos

Website Photos

Participating in audits conducted by the NDIS Commission for our business, including...

its auditors

The recording of your personal information in audio and/or visual format

None of the above

Dietary Needs

I have the following allergies/intolerances, and my favorite food is...

No Dietary Needs

Yes

Vegetarian

Yes

Vegan

Yes

I have allergies to (please list)

I cannot consume (sensory/intolerances)

My favourite food is…

Care28 can assist me during mealtimes by...

I can identify which foods are safe for me to eat (if required due to allergy or dietary requirements).

If I have a food allergy, I have provided Care28 with a management plan.

If necessary, I will bring any medications to assist with my allergy and have completed the relevant medical forms.

I prefer to provide my own food and will do so.

Mental Well-being

I have/experience…

Depression

Anxiety

Psychosis

Schizophrenia

Bipolar

Other

I would like Care28 to assist me in managing this by...

My triggers may include…

I am supported/linked with the following organizations who assist me... (Please supply relevant management plans.)

I have received medical support to assist me, and Care28 has a copy of any relevant management plans to help me manage.

Physical Well-being

Allergies to:

I am taking the following medications:

Medication List:

I would like Care28 to assist me in managing this by...

Practical Support Needs Please select the boxes that best represent you and your support needs:

Traffic awareness

I can do independently

I need some assistance.

I cannot do independently

Staying with the group

I can do independently

I need some assistance.

I cannot do independently

Appropriate Communication

I can do independently

I need some assistance.

I cannot do independently

Personal Space Awareness

I can do independently

I need some assistance.

I cannot do independently

Respecting Personal Boundaries

I can do independently

I need some assistance.

I cannot do independently

Safe Car Travel

I can do independently

I need some assistance.

I cannot do independently

Following instructions

I can do independently

I need some assistance.

I cannot do independently

Swimming and Water Safety

I can do independently

I need some assistance.

I cannot do independently

I can manage my own spending money.

I can do independently

I need some assistance.

I cannot do independently

I am comfortable with my sleeping routine.

I can do independently

I need some assistance.

I cannot do independently

Swimming and Water Safety

I can do independently

I need some assistance.

I cannot do independently

Swimming and Water Safety

I can do independently

I need some assistance.

I cannot do independently

Care28 can assist me by…

I have provided Care28 with any relevant behavior plans for assisting me when required.

Tell us a bit about yourself and your goals. To help us understand you better, please fill out the form below:

My strengths are (what I am good at)…

I like…

I don’t like… (please include any sensory considerations)

You will know when I am happy by…

You will know when I am unhappy by…

I prefer to communicate by…

How have these goals changed since your previous Support Plan (if applicable)?

How does your existing support from us or other providers help achieve desired outcomes? Is there any opportunity to use less intrusive options, in accordance with contemporary evidence-informed practices that meet participant needs and help achieve desired outcomes?

Health requirements

Activity

Continence with regular bowel and bladder function

Management of Constipation, Diarrhea, or Incontinence (including medication, supplements, pads)

Medical Interventions (such as catheter, stoma bag)

Outline the condition, treatments, aids/assistance required, who will provide them, and when.

Skin Health

No Skin Issues

Minor Skin Issues (rash, skin treatments)

Pressure Sores (current, at risk, or history)

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Swallowing Function

No Swallowing Difficulties

Minor Swallowing Issues (choking, coughing during meals, reduced appetite)

Severe Swallowing Difficulties (modified diet, feeding tube)

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Healthcare Professionals

Received a GP check-up in the last 12 months

Regularly visit a specialist

Have a Case Manager/Support Coordinator

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Muscular pain

No pain

Moderate Pain

Severe Pain

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Nerve pain

No Pain

Moderate Pain

Severe Pain

Please outline the condition, required treatments, aids/assistance needed, who will provide them, and when.

Falls Risk

No Falls in Past 12 Months

Less Than 3 Falls with No Serious Injury in the Past 12 Months

More Than 3 Falls or Serious Injury from a Fall in the Past Year

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Muscle-related Issues (excluding pain)

No problems

Muscle Weakness, Tremors, Spasms, Spasticity, or Balance Issues

Severe Muscle Weakness, Tremors, Spasticity, or Balance Issues

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Other Health Issues

Fatigue

Visual Disturbance

Temperature Intolerance

Other Medical Conditions

Please provide details of the condition, necessary treatments, required aids/assistance, who will provide them, and when.

Social Needs

Family:

Describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).

Hobbies & Interests:

Describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).

Religion & spirituality:

Please describe how you would like to engage in this activity.

Please provide details of the activity, including the time spent, assistance required, who will provide it, and when (including vouchers).