Client Intake Form

Personal Details

Edelweiss Care is committed to protecting the Occupational Health and Safety of all workers and participant/clients. To ensure this requirement is met, the first 15 minutes of every new service will include a risk assessment to be carried out by the support worker

Participant First Name
Participant Last name

Participant Phone Number

(if applicable)

Gender

D.O.B.

NDIS Participant Number

Parents/Guardians NamesIncluding contact details of next of kin

AddressIncluding property access details

Email address:

Sibling Information Including names/gender/ages/additional needs

Information about Client Social interactions and interests. Information regarding other services client may be receiving

Cultural Identity Including any spiritual, cultural and religious preferences. Do you identify as an Aboriginal or Torres Strait Islander?

Family Structure/Living Arrangements

Do you live on your own *

Pets - Animals

Type of animals
Are the pets:

Communication & Language Method of communication? Verbal – fluent in English, use single words, use simple sentences, or short phrases? Non-Verbal – sign language, pictorial system, electronic devices, gestures, body language, vocalisations/sounds?

Are there any weapons or firearms located in the Home? *
Are the items locked away during service delivery? *

Medical Information

Health and Wellbeing Information regarding primary/secondary diagnosis

Does the Diagnosis include a Mental Health component?  If yes, please specify details in full.

*As our organization does not specialize in mental health, the participant must be well managed and not display aggressive behaviours.  Support will be negotiated on a case-by-case basis.  If we feel we cannot meet the specific needs, we will discuss referral to another specialist provider

Does the Diagnosis include a Mental Health component? *

Medical Information/Alerts (Asthma, anaphylaxis, diabetes, epilepsy etc)

Medication Requirements Is there a requirement for the support worker to assist with medication? If yes, provide all details including a copy of MEDICAL AUTHORITY/MEDICAL TREATMENT

Screening for COVID-19 Due to recent events globally can you please answer the attached for screening purposes. As a duty of care for our support workers we require the following information.

Have you resided or travelled overseas in the last 3 months? *
Has anyone residing in your home resided or travelled overseas in the last 3 months? *
Have you shown any symptom of COVID-19 in the last 4 weeks? *
Have you been in contact with any persons that tested positive for COVID-19 in the last 4 weeks? *

Cognition Comprehension of surroundings, directions or instructions

Food preferences and dietary requirements Please provide specifics

Mobility Please describe the participants level of mobility.

If aids are used, please provide details, eg: frame, wheelchair

Equipment Please detail any assistive equipment that might be required

Equipment used type:

Wheelchair *
Walker *
Hoist *

Is manual handling Required Is hoist/lift/transfer required?

If yes: specify requirement *

Home Risk Assessment

To identify any hazards or risks in the home where service delivery will take place.  This is to ensure the safety of both you and our workers.

I acknowledge that my first service will include the completion of a home risk assessment by the support worker.

Tick box to confirm

Individual Risk Assessment

Allergy Information Please provide details.

Individual Risk Profile Due to their disability or medical conditions what are related risks to the participant.

We need to know the possible risks that are associated to the participant such as:

Behaviours of Concern List of behaviours/triggers & strategies to assist

Behaviours of Concern *

Excessive Fears eg. Touch, loud noises, please provide triggers & strategies to assist

Emergency Procedure Please note any specific home or location escape routes in the event of fire. Include location of First Aid

Fire alarms installed. *

Service Requirements and Goals

Required Services.

Preferred day of the week and time AIHC will endeavour to meet your requirement, unfortunately this is not always possible. We will try and accommodate your request as close to preferred day and time if possible

Assistance and support required with personal care

Goals Please include your main goals as relevant from your NDIS plan. What are you hoping to achieve from our services?

Money Handling

Is there a requirement for the support worker to handle any cash/debit or credit cards? *

Carer Requirements Including gender, experience, age, personality type etc

Gender *
Age *

NDIS Funding Information

NDIS Plan Information

Please provide the start and end dates of your NDIS Plan:

Please tick how your NDIS funding is managed:

please provide details for invoicing purposes below

Funding Outline of funding you wish to use. E.g. 3 hours per week respite, 2 hours per fortnight community participation

Personal Care / Respite

Community Participation

Life Skills Development /Travel Training

Household Tasks

Community Nursing Care

Is Transport required? Please describe needs. *Please refer to transporting client’s policy below

Is Transport required?

Invoice or claim from:

Are you using other Providers for services? If yes, in what capacity ie: for what services?

My Support Coordinators Name

(if applicable)

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