ATS New Client Intake Form

New Client Intake Form

Client Information

Name of person completing this form: *As seen on legal documentation

Contact number of person completing this form: *As seen on legal documentation

ALL INFORMATION BELOW IS REFFERING TO THE CLIENT

Date Of Birth *

Phone/Mobile Number

Email address for correspondence *

Address: *

Street address *

City *

State *

Postcode *

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 Name, Number and Email: *

Emergency Contact Relation *As seen on legal documentation

NDIS Numberif applicable

Funding manger name:

Funding manager e-mail:

Please upload your NDIS, Aged/Home Care Plan

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About the client

Anaphylaxis, Asthma or Epilepsy? *

Anaphylaxis AsthmaEpilepsyNone

Allergies or Intolerances *

If you answered "other" please explain

Disability/Medical Condition *

Please tell us how the disability / condition affects daily life *

Is there notable or concerning behaviours we should look out for? *

YesNo

If yes, please provide details

Is there a current behaviour Support Plan in action? *

Yes (please attach at the end of this form)No

Please advise is there is a diagnosed mental health condition *

YesNo

If yes, Please provide further details

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?

Assistive Technology or Communiation Methods we should be aware of

Please tell us about any specialists and/or supports currently being accessed:

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

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

Please upload all relevant Documentation including Behaviour/Risk Alerts

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Support Preferences

Preferred Support Ratio

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

Likes: *Tell us about your/clients strengths and enjoyments

Dislikes: *Tell us about your/clients dislikes and things we should avoid

Current Occupation *

EmployedStudyingNA

Current living arrangements *

Information about others involved in daily life that would be good to know e.g family, friends and formal supports *

Please advise any further support preferences or things we should know *Please 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

Please upload any other relevant documentation

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Save and Complete Later