ATS New Client Intake Form

New Client Intake Form

Client Information

First & Middle Names *

Last Name *

Date Of Birth *

Phone/Mobile Number *

Email Address

Address: *

Street address *

City *

State *

Postcode *

Please provide details

Country of Birth *

Are you of Aboriginal or Torres Strait Islander origin?

YesNo

Cultural background & requirements:Do you follow a religion, have any cultural needs or beliefs that we need to be aware of

Emergency Contact Details:

NDIS Numberif applicable

Funding manger name:

Funding manager e-mail:

Please upload your NDIS, Aged/Home Care Plan

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About you

Disability/Medical Condition *

Please tell us how your disability / condition affects your daily life

Please provide details of any significant medical conditions and any medications currently being taken:

Have there been any recent hospitalisations related to the medical condition or disability?

Please tell us about any specialists and/or supports you currently access:

Information about others involved in your life such as family, friends and formal supports:

Name, phone number and address of your GP and/or Specialists

If you answered "other" what is it?

Do you have Anaphylaxis, Asthma or Epilepsy?

Anaphylaxis AsthmaEpilepsy

Please upload all relevant Medical Condition plans, including Anaphylaxis, Asthma, Allergy, Mental Health Safety Plans

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Note that if you have any of the above conditions, you must provide us with a copy of your medical management plan

Communication and Sensory Preferences:Tell us how you like to communicate and anything we need to know about how you interact with the world

TransportTell us if you need support with transportation and what that means for you

Do you have a mental health condition

YesNo

Do you exhibit any behaviours of concern? *

YesNo

If yes, please provide details

Do you have a Behaviour Support Plan?

Please upload all relevant Documentation including Behaviour/Risk Alerts

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Likes:Tell us about your strengths and the things you enjoy

Dislikes:Tell us about the things you don’t like or want to avoid

Your support preferencesPlease tell us how you like to be supported, do you preferences for specific staff members, days and times of support or any thing you don’t want in a support worker

Are you employed or studying?

Anything else you would like us to know?

Please upload any other relevant documentation

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