NDIS Participant Intake Form - Asina Disability Support

1 Participant Details GeneralSupport

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Intake Date

Full Name

Preferred Name / Nickname

Preferred Gender of Support Worker

Address

Phone

Date of Birth

Email

Gender

Marital Status

Country of Birth

Main Language Spoken at Home

Aboriginal/Torres Strait Islander Identification

Yes No

Religious/Cultural/Personal Matters Awareness

Yes No

Please specify

Living Arrangements

Lives alone With family With others With extended family

Current School/Training/Day Activity/Workplace

2 Primary Carer Details GeneralEmergency

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Name

Relationship

Address

Phone

Email

3 Secondary/Emergency Contact Details Emergency

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Name

Relationship

Address

Phone

Email

Second Emergency Contact

Name

Relationship

Address

Phone

Email

4 Nature of Disability RiskSupportEmergency

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Description of Disability

Verbal

Yes No

Ambulant

Yes No

Uses Wheelchair

Yes No

History of Falls?

Yes No

Please describe (frequency, circumstances, injuries)

Mobility Aids Used?

Walker/Frame Walking Stick Handrails Required Hoist/Lifter None

Sensory Sensitivities?

Yes No

Which sensitivities apply?

Noise Light Textures Crowds Smells Touch

Additional details

5 Medication Details EmergencyRisk

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Medication Assistance Required?

Yes No

Name of Medications and What For

PRN Medication Required?

Yes No

PRN Medication Details

Doctor's Letter with Medication Details

Upload doctor's letter

PDF, Word, or image — max 10MB

Other Medical Conditions?

Yes No

Please specify

Other Aides Required?

Yes No

Please specify

Substance Use (Alcohol/Drugs)?

Yes No

Please specify (type, frequency, known risks)

6 Medical Information Emergency

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Doctor's Name

Doctor's Phone

Clinic Name

Clinic Address

Specialist Name

Specialist Phone

Specialist Address

Speciality

Medicare Number

Health Care Card Number

Companion Card Number

Companion Card Exp Date

Disability Pension

Emergency Medical Details

Preferred Hospital

Ambulance Cover?

Yes No

Membership Number

Current GP Mental Health Plan?

Yes No

7 Health Conditions EmergencyRisk

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Asthma

Yes No

Upload Asthma Management Plan

Upload management plan

PDF, Word, or image — max 10MB

Epilepsy

Yes No

Upload Epilepsy Management Plan

Upload management plan

PDF, Word, or image — max 10MB

Diabetes

Yes No

Upload Diabetes Management Plan

Upload management plan

PDF, Word, or image — max 10MB

Allergies

Yes No

Upload Allergy Management Plan

Upload allergy management plan

PDF, Word, or image — max 10MB

Upload Anaphylaxis Plan

Upload anaphylaxis plan

PDF, Word, or image — max 10MB

Swallowing / Choking Risk (Dysphagia)?

Yes No

Modified Food Texture Required?

Modified Fluid Consistency?

Additional details / management strategies

Upload Mealtime Management Plan

Upload mealtime management plan

PDF, Word, or image — max 10MB

8 Communication SupportRisk

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Understands Everything Said?

Yes No

Please specify

Communication Methods

Speech Vocalising/Noise Gestures Communication Aid Signing Facial Expressions Writing Skills Reading Skills Interpreter Required

Additional Communication Notes

9 Care Issues Risk

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Reaction to New Carers

Positive Negative Needs Encouragement

Reaction to Others

Positive Negative Needs Encouragement

Has Fears?

Yes No

Please specify

Road Traffic Awareness?

Yes No

Please specify

Aware of Danger?

Yes No

Please specify

Risk Taking Behaviour?

Yes No

Please specify

Likely to Wander/Run/Hide?

Yes No

Please specify

Likely to Damage Property?

Yes No

Please specify

Likely to Steal/Shoplift?

Yes No

Please specify

History of Absconding from a Service or Home?

Yes No

Please describe (when, where, what happened)

Known Triggers for Medical Episodes?

Yes No

Please describe triggers and warning signs (e.g., seizure triggers, asthma triggers)

10 Behavioural Issues RiskSupport

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Likely to Exhibit Inappropriate Behaviour?

Yes No

Bad Language

Physical

Social

Verbal

Aggression

Sexual

Other

Behaviour Inflicted on Self or Others?

Yes No

Triggers and Management Details

Calming Object/Sensory Item?

Yes No

Please specify

Behaviour Management Plan?

Yes No

Upload Behaviour Management Plan

Upload behaviour management plan

PDF, Word, or image — max 10MB

History of Self-Harm?

Yes No

Please describe (type, frequency, known triggers, current management)

11 Meals/Nutrition SupportRisk

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Special Eating Aids Needed?

Yes No

Please specify

Assistance with Meals?

Yes No

Please specify

Healthy Snacks/Meals Enjoyed

Foods Cannot Have?

Yes No

Please specify foods

Reason

Allergy Dislike Preference Other

Allergy Management Plan (Food) Supplied?

Yes No

Drinking Assistance Required?

Yes No

Please specify

Drinks Cannot Have?

Yes No

Please specify drinks

Reason

Allergy Dislike Preference Other

Allergy Management Plan (Drinks) Supplied?

Yes No

General Meal Preferences & Favourite Foods

12 Physical Activity/Sports Support

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Activities Enjoyed

Can Swim?

Yes No

Upload Swimming Assessment & Consent Letter

Upload swimming assessment

PDF, Word, or image — max 10MB

General Likes, Interests & Hobbies

Dislikes & Things to Avoid

13 Personal Care/Hygiene Support

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Instructions: For each item, select: Independent, With prompting, With assistance, Not at all, or N/A

Wash Hands

Shower/Bath

Wash/Rinse Hair

Dry Themselves

Dress/Undress

Comb Hair

Clean Teeth

Use Toilet

Wipe Themselves

Shave

Manage Menstruation

Bladder/Bowel Control?

Yes No

Assistance Required?

Yes No

Please specify

Continence Products Required?

Yes No

Please specify

Shower or Bath Preference?

Shower Bath

Time Preferred?

AM PM

14 Sleeping Support

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Bedtime

Wake Time

Difficulty Sleeping?

Yes No

Please specify

Active Overnight Person Required?

Yes No

Please specify

Night Light/Sleeping Aide?

Yes No

Please specify

Sleeps Well?

Yes No

Please specify

Condition Affecting Sleep?

Yes No

Please specify

Daily Routine Preferences

Morning Routine

Evening Routine

15 Legal/Custody Restrictions Risk

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Access Alert/Court Order/Legal Order?

Yes No

Access Type

Court Order Family Law Order Restraining Order Community Treatment Order Other

Description of Order

Copy Supplied?

Yes No

Reason why not

16 General Comments General

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Additional Details

17 Service Feedback General

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How Did You Find Out About Us?

Other services Social Media NDIS Service Directory Support Coordinator/Plan Manager Family/Friend Other

18 NDIS/Support Plan Support

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Funding Type

NDIS Private Other

Has NDIS Plan?

Yes No

Plan attached?

NDIS Number

Plan Review Date

How Funding Managed?

NDIA Agency Plan Managed Self Managed

Service Start Date

Service Finish Date

Participant Goals

Upload NDIS Plan / Goals Document

Upload NDIS plan or goals document

PDF, Word, or image — max 10MB per file — you can select multiple files

Hours of Service & Frequency

Support Level

Type of Support/Support Area

Budget

Personal Goals & Aspirations

Personal Goals (Beyond NDIS Plan)

Transport

Transport Independence

Has Own Vehicle?

Yes No

19 Consent

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Important: Please read each item carefully and confirm your consent. You may withdraw consent at any time by notifying Asina in writing.

20 Supporting Documents

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Upload any relevant documentation such as NDIS plans, referral letters, medical reports, court orders, or other supporting documents.

Upload Documents

Click or drag files here to upload

PDF, Word, Excel, or images — max 10MB per file — select multiple files at once

21 Declaration & Signature

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Parent(s) / legal guardian(s) must sign if the participant is under 18 or unable to sign independently.

Full Name of Participant / Guardian

Full Name of Nominee (if applicable)

Relationship to Participant

Date

I declare that the information provided in this form is true and correct to the best of my knowledge. I understand that providing false or misleading information may affect the delivery of services.

Signature

Sign above using your mouse or finger

Second Signature (if required — e.g. second parent/guardian)

Second signature (optional)

Participant Intake Form

Why do we need this information?

1 Participant Details GeneralSupport

2 Primary Carer Details GeneralEmergency

3 Secondary/Emergency Contact Details Emergency

4 Nature of Disability RiskSupportEmergency

5 Medication Details EmergencyRisk

6 Medical Information Emergency

7 Health Conditions EmergencyRisk

8 Communication SupportRisk

9 Care Issues Risk

10 Behavioural Issues RiskSupport

11 Meals/Nutrition SupportRisk

12 Physical Activity/Sports Support

13 Personal Care/Hygiene Support

14 Sleeping Support

15 Legal/Custody Restrictions Risk

16 General Comments General

17 Service Feedback General

18 NDIS/Support Plan Support

19 Consent

20 Supporting Documents

21 Declaration & Signature