CLIENT INTAKE FORM

Please note that as an unregistered provider we are unable to use restrictive practices.

This form can be saved and completed later.

If you would like assistance to complete please contact us or

if you feel this form could be improved please email shay@radsupport.com.au or phone 08 7530 5719

RADS Primary Purpose

Creating Community Connections

General Information

Client First Name *

Client Surname *

Date of birth *

Email Address (if over 18 years)

Phone Number (if over 18 years)

Home Address *

Are you under Guardianship or use a Representative for communication?

Under 18 years of ageGuardianshipRepresentativeCarer

Name of Representative/Guardian/Parent/Carer

Mobile Number:

Email address

Preferred Method of Communication

PhoneTextEmailAll of the above

Current living arrangement

Emergency Contact Information

Same as Representative/Guardian/Parent/Carer

Emergency contact

Phone

Emergency contact’s relationship to you

NDIS Information

Support Coordination or LAC details (phone and email)

Upload NDIS Plan or relevant section

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Is a Quote or Schedule of Supports required? *

YesNo Unsure

About You

If boxes provided are inadequate please use the boxes 'Additional Information'' at the bottom of each section

Are any of these applicable to you

For the purpose of informing your support workers about your needs, would you like to share your disability/disabilities?

Medical Information

I Take The Following Medications and

I do not require assistance I require assistance

Please list any medications you are currently taking for the purpose of relaying critical information to medical personnel in an emergency or upload a medication summary, current charts, complex health care plan, CMI for current medications.

I agree to contact RADS immediately with medication changes if RADS are assisting me with my medications *

Medication Summary from your GP/Chemist

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Are there any medical conditions support workers could be aware of to better support you?

If your medications cause any symptoms that would be helpful for support workers to be aware of, please describe

Emergency Medication Management Plan (if applicable)

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Please list any allergies

Allergy

Severity

Anaphylaxis Action Plan

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PLANS (Other)

Do you have a current Positive Behaviour Support Plan? *

Are there any Restrictive Practices in your plan?

Yes No

Please know that we are an un-registered provider and therefore cannot use restrictive practices.

If applicable, please upload one or multiple health care plans

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Complex Health Care Plans and/or recommended actions and any relevant reports from your doctor- i.e stress management, bowel care, Mental Health, Seizure Management

https://epilepsyfoundation.org.au/understanding-epilepsy/epilepsy-and-seizure-management-tools/epilepsy-plans/

Additional InformationPlease detail any medical conditions staff should be aware of prior to commencing support

Schedule of Supports

Your support worker can support you to achieve the goals in your NDIS plan. By getting to know you and building a strong relationship, you can achieve more successful outcomes together.

Are supports to be provided on public holidays

YesNoWhen Scheduled

Nominate days, AM/PM and times if known

Supports Needs

Support Worker PreferenceE.g male, female, peer aged

Would you prefer

A meet and greet with new staffShadow shifts with new staffBothNeither required

Evidence Reports

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E.g. School, GP, Specialists, Allied Health, Mental Health, Service Providers, Hospital, Community Health, Other

MISC

Do you have a Companion Card?

YesNoI am awaiting approval

The Companion Card is for people with a significant and permanent disability, who require attendant care support in order to participate at community venues and activities. For more information and to download the form click this link

https://www.sa.gov.au/topics/care-and-support/disability/companion-card

You can apply for a Companion Card if you can demonstrate all of the following.

you live in South Australia
you have a significant and permanent disabililty
due to the impact of your diability you are unable to pariticpate at most community venues and activities without attendant care support
you need for this level of support will be lifelong

Any Geographical Requirements/ Access to property Info/ Key Codes

Additional Information or Comments

Additional Information - About your homePlease describe anything about her home that support staff may need to know prior to commencing support e.g pets

About Me

What makes you happy:

What people appreciate about you and admire about you:E.g. easy going, friendly, quiet, funny

Interests, strengths and skills:Members of a club, sports, arts, likes, dislikes, hobbies, singing, dancing, theatre

What is important to you:E.g. pets, family, health, having fun

How can RADS support workers, leaders, office staff and management best support you?E.g I need to feel motivated to get out of bed, please do not speak too loudly, include me in conversations, please tell me if there are new staff on my team, I do not like change, I would like to be invited to all social events

Do you:

Work in disability employment Work in open employmentVolunteer

Would you like to work or volunteer:

YesNoMaybe

Consent to Share Information

I give my consent to RADS - Recreation and Active Disability Support, the right to take and display photograps containing my image. The photographs may at times be displayed on RADS website and social media pages.

YesNo

Record of Client Consent

My worker and/or representative has discussed with me how and why certain information about me may need to be provided to my nominated providers.

I understand the recommendations and I give my permission for the information to be shared as detailed above.

I consent for RADS to share 'need to know' information with the belowSupport Coordinators, Plan Managers, Other

My external supports are:E.g. GP, Allied Health Professionals, Other providers. Please include name, their role and contact details (phone & email)

RADS has a smoke-free policy. Clients and staff must not engage in any smoking whilst in enclosed spaces including the home and vehicles. There is no safe level of exposure to second-hand smoke. Do you agree to ensure you follow RADS smoke-free policy? *

YesNo

Client/Representative Signature *

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First and Last Name of Signee *

Date *

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