Referrer Details

Name of Referrer
Referral Organization
Mobile
Phone
Email
Position
Address

NDIS Participant Details

Full Name
Date of Birth
Place of Birth
Gender
Mobile
Phone
Address
Suburb
State
Post Code
Residential Type
Others REsidential
Preferred Language
Interpreter Required?

Participant’s NDIS Plan Details

Participant NDIS Number
Payment Management
Plan Manager Name
Plan Manager Contact Number
Plan Manager Email Address
Plan Start Date
Plan End Date
Upload NDIS

Emergency Contact Person Details

Full name
Mobile number
Phone number
Relationship with the participant

Guardian Details

Name
Email
Mobile Number
Phone Number

NDIS Services Required

Services Assist-personal Activities
Assist-Travel Transport
Innovative Community Participation
Household Tasks
Therapeutic Support
Participate Community
Please write the service details

Participant Diagnosis

Participant Risk Assessment

Communication Risk (Like Hearing, Speech, Able to write & English language skills.)
Cognition (Like short term memory issues, directions acceptance, time oriented & willing to participate in the support.)
Mobility (Like Walk unaided, Manages stairs unaided, Uses walking aid to walk, Uses self-propelled wheelchair, Uses electric wheelchair/ scooter, Transfers independently, Transfers with supervision, Transfers with hoist)
Personal Care Assistance Required (Like Bed mobility, Showering, Toileting, Grooming, Repositioning in bed, Repositioning in chair, Mouth care, Eating, Skin care)
Violence Risk (Like Physical aggressio, Verbal aggression, Self-harm, Substance abuse, Sexual abuse)

Potential Issues For Staff Visiting

Potential Issues For Staff Visiting NonePets on the propertyFirearmsAlcohol or Drugs useOthers

Anything else we should know?

Participant Consent Section

Participant Consent Section
I understand that the following service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services, in order that I receive the best possible service:
I understand that the service must comply with relevant privacy laws and I will contact the organization immediately if I feel that these laws have been breached.
Golden Plus Care will protect and store all my information in a locked file, and will not distribute my documents other than the listed services mentioned above.
Management has discussed with me how and why certain information about me may need to be provided to other service providers.
I understand that recommendation and I give my permission for the information to be shared with the people or agencies as detailed above.
I agree with auditing bodies to access my files for review of Golden Plus Care Quality assessment.

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