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Participant's details

Participant's name

D.O.B

Gender

Residential address

Postal address (if different from above)

Mobile

Phone

Email address

Preferred option for communication

Phone Email

Language spoken at home

Interpreter required

Is there a guardianship and/or administration order in place?

For participants under the age of 18 years of age, under guardianship
or in the care of family or caregivers please complete below

Name of parent/guardians

Primary carer

Lives with participants

Emergency contact

Relationship to participant

Residential address (if different from participant's)

Postal address (if different from participant's)

Mobile

Phone

Email address

2. Goals and aspirations

What do you want to achieve for yourself - life skills, physically, socially etc

Immediately

In 3/6 months

Next year

I understand

I understand that: These records are owned by this organisation information within these records will be shared with other staff within the organisation on and only when staff require the information to carry out their duties I can ask to see records and receive a copy records are archived for a set period according to policy and procedure I understand that all information obtained will be kept confidential To the best of my knowledge, the information provided in this form is true and correct.

4. Funding

NDIS number

NDIS date

5. Plan manager details

How is your plan managed

Name

Phone

Email address

Preferred option for communication

Phone Email

7. Preferences

Preferred name

Religious requirements

Cultural requirements

Communication device

Physical assistance

Other considerations

8. Disability/medical conditions

Disability / medical conditions including any diagnosis if relevant

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