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Participant Intake – Form

Participant Intake

Participant Details

Participant Name

Date

MM slash DD slash YYYY

Gender

NDIS Number

Home number

Phone Number

Language spoken at home:

Interpreter required

Yes

Preferred option for communication

Post

Phone

Do you identify as Aboriginal and Torres Strait Islander?

Yes

Residential Address:

Postal Address (if different from above):

Is there a Guardianship and/or Administration order in place?

Yes

Is there a Behaviour Management Plan in place?

Yes

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/Guardian 1

Primary Carer

Yes

Lives with Participant

Yes

Emergency Contact

Yes

Relationship to participant

Guardian

Caregiver

Other

Residential Address:

Postal Address (if different from above):

Home number

Phone Number

Name of Parent/Guardian 1

Primary Carer

Yes

Lives with Participant

Yes

Emergency Contact

Yes

Relationship to participant

Guardian

Caregiver

Other

Residential Address:

Postal Address (if different from above):

Home number

Phone Number

2.Disability / Medical Conditions including any diagnosis if relevant.

text

Behaviour Support Plan documents collected for authorisation purposes

Yes

(if relevant)

Behaviour Support Plan available on NDIS portal?

Yes

Other service providers currently using (include Specialist Behaviour Support Provider, if relevant)

Name

Address:

Phone Number

Frequency of use:

Name

Address:

Phone Number

Frequency of use:

Name

Address:

Phone Number

Medicare Number

3.Health Care Information

Frequency of use:

Expiry Date:

MM slash DD slash YYYY

Reference Number:

Private Healthcare Provider

Membership Number

Reference Number

NDIS Number:

Phone Number

Address

4.Funding

NDIS Managed (A copy of the NDIS plan MUST BE provided for NDIA managed participants)

NDIS Number:

NDIS Date:

MM slash DD slash YYYY

Plan Managed

Self-Managed

Plan Managed

Name

Comments

5.Preferences

Preferred name

Religious Requirements

Cultural Requirements

Communication device

Physical Assistance

Other Considerations

Hobbies and activities of interest

6.Goals and Aspirations

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

Immediately

In 6 months

Next year

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:

Participant Signature or Parent / caregiver signature

Name of person signing

Relationship to the participant, if not the participant

Date

MM slash DD slash YYYY

Note: Authority to Act as and Advocate form is required if the individual signing this form is not the participant.

Personalised Support That Puts You First

At NASP, we know every person is unique. That’s why we work closely with you to
tailor support around your goals, preferences, and lifestyle—making sure it’s
meaningful, respectful, and empowering.

Contact us

03 7037 6054
0401 202 022
Info@nasp.com.au

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Acknowledgement

NASP acknowledges and pays respect to the Traditional Custodians and Owners of the lands on which we live and work.

We recognise the enduring connection of Aboriginal and Torres Strait Islander peoples to Country, culture, and community.
We honour their rich history, traditions, and ongoing contributions, and we are committed to working in a way that promotes respect, inclusion, and wellbeing for all who call Australia home.

For more information about our commitment and how we operate, please don’t hesitate to contact our team.

Participant Intake

Table of Contents

Participant Details

2.Disability / Medical Conditions including any diagnosis if relevant.

3.Health Care Information

4.Funding

5.Preferences

6.Goals and Aspirations

Personalised Support That Puts You First

Contact us

Useful links

Acknowledgement

NASP acknowledges and pays respect to the Traditional Custodians and Owners of the lands on which we live and work.