This form can be completed by yourself or a member of your network of support. 

If you require any assistance in completing this form, please contact our NDIS team on 02 4979 1120 or ccenquiries@catholiccare.org.au

Participant Details

NDIS No.

Plan Dates

 

Name

Preferred Name

Email AddressEnter referrer's email address if form being submitted by referrer.

Home Phone No.

Mobile No.

Gender

MaleFemaleOther

Pronouns

HeSheThey

Date of Birth

Residential Address

Preferred method of communication

EmailPhonePostSMS

Do you have a copy of your NDIS plan?

YesNo

Please upload your NDIS plan

Browse

Do you have a copy of your Positive Behaviour Support plan that you are willing to provide?

YesNoN/A

Please upload your positive behaviour support plan

Browse

Is an interpreter required?

YesNoN/A

If yes, please complete a Cultural Assessment form.

Are you being referred by someone?

YesNo

If yes, please complete the referrer's details in the next section.

Referrer’s Details

Please leave this section blank if this is a self-referral.

Name

Email

Phone Number

Relationship to participantCase managerFamily memberLegal guardianParticipant Primary carerSupport coordinator Other

 

Plan Details

Is your plan

Self-managedPortal managedUsing a plan managed provider

Who is the provider?

Can you provide the Consent Form?

YesNoN/A

Do you provide CatholicCare with consent to share information to support you in ensuring services are in line with NDIS budget?

YesNo

Are you transitioning from another provider?

YesNo

Please provide details

Do you provide consent to share information with this provider?

YesNo

Do you require a transition from another provider to support your continuity of care?

YesNo

If yes, provide details (buddy shifts, transition meeting)

About the Participant

Primary Disability: Select one only

Acquired Brain InjuryAutism Cognitive/Neurological Developmental delayIntellectualPhysical PsychologicalSensorySpecific learning

Severity

MildMediumSevere

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Secondary Disability: Select as required

Acquired Brain InjuryAutism Cognitive/Neurological Developmental delayIntellectualPhysical PsychologicalSensorySpecific learning

Severity

MildMediumSevere

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Country of Birth

Ethnicity

Language used at home

Australian Citizen?

YesNo

Accommodation status

Lives with others – Please provide details belowLives alone – Complete risk analysis

* you will be asked to complete risk analysis with the NDIS team

Accommodation details

Emergency Contact information

Name

Relationship

Contact Number

Secondary Number

Plan in the event emergency contact cannot be contacted

Do you consent to share information with emergency contact?

YesNo

If Yes, ensure this is added to the Consent Form.

Risk Indicators

Large/aggressive animals in the home or on the premises?

YesNo

Are there any weapons in the house?

YesNo

History of dangerous behaviour?

YesNo

(may emerge during discussion of presenting issues)

Episodes of family violence?

YesNo

(may emerge during discussion of presenting issues)

Mental health issues or illness?

YesNo

(will have emerged during discussion of disabilities)

Other family members in the home – might they present risk?

YesNo

(should emerge during discussion of living conditions)

Environmental Hazards?

YesNo

(If yes, provide details below)

 

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Medical conditions

Allergies

Conditions

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Are there any identified restrictive practices in your plan or current supports?

YesNo

NOTE: CatholicCare are unable to provide any restrictive practice supports if we do not have a current Positive Behaviour Support Plan and our support workers have not been provided with adequate training from the behaviour support provider.

 

Do you agree to supporting CatholicCare in formulating a risk assessment with you?

YesNo

NOTE: If No, CatholicCare may not be able to provide a service to you.

Do you require support to create an emergency response plan?

YesNo

What supports do you have in place?

Do you require supports to access a Covid-19 vaccination?

YesNo

What do you require?

InformationSupport to have vaccinationCovid Safety Plan

What supports have you previously accessed?

Support Being Requested

Direct Supports

In homeCommunity AccessPersonal Care Transport Other

 

Support Coordination

Level 1Level 2Level 3

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Preferred days

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Preferred times - Morning

 

Preferred times - Afternoon

 

Preferred times - Evening

 

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Information to be included in the Support Plan

Mealtime Management Plan N/A

 

Browse

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Medication Management PlanN/A

 

Browse

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Money and Property Management PlanN/A

 

Browse

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Other

 

Browse

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Do you have a

Disability Parking Pass Companion Card

Are you interested in being a part of CatholicCare’s Focus Group to share your views regarding current and future services provided?

YesNo

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