Townsville Support Solutions - NDIS Intake Form

📋 How to Use This Form:
1. Print this form (print dialog should open automatically)
2. Fill out all sections completely and legibly
3. Return completed form to: 1 Jones Street, Townsville QLD 4810 OR email to: [email protected]
Questions? Call us: (07) 4453 2220 (Monday-Friday 9am-5pm)

1. PARTICIPANT INFORMATION

Full Legal Name (as per NDIS plan):

Preferred Name:

Date of Birth:

Gender:

NDIS Number:

Medicare Number:

2. CONTACT INFORMATION

Residential Address:

Suburb:

Postcode:

State:

Mobile Phone:

Home Phone:

Email Address:

Preferred Method of Contact:

Phone

SMS/Text

Mail

3. EMERGENCY CONTACT INFORMATION

Primary Emergency Contact:

Full Name:

Relationship to Participant:

Phone Number:

Email (if available):

Secondary Emergency Contact (Optional):

Full Name:

Relationship to Participant:

Phone Number:

Email (if available):

4. NDIS PLAN DETAILS

NDIS Plan Start Date:

NDIS Plan End Date:

Plan Management Type:

Self-Managed

Plan-Managed (requires Plan Manager details below)

NDIA-Managed

If Plan-Managed, provide Plan Manager details:

Plan Manager Name/Company:

Plan Manager Contact Number:

Plan Manager Email:

5. DISABILITY & SUPPORT NEEDS

Primary Disability:

Other Disabilities/Conditions:

Communication Needs (e.g., verbal, non-verbal, communication devices, interpreter):

Mobility Needs (e.g., wheelchair, walker, assistance required):

Behavioural Support Needs (if any):

6. MEDICAL INFORMATION

Medical Conditions (e.g., epilepsy, diabetes, heart condition):

Allergies (medications, food, environmental):

Current Medications (please list all):

GP Name:

GP Phone:

GP Address/Clinic:

7. SERVICES REQUIRED

Please select the services you require from Townsville Support Solutions:

In-home Care & Personal Care

Assisting with Daily Living Activities (cleaning, cooking, shopping)

Community Access Support (appointments, social activities)

Level 2 Support Coordination

Group Activities at Centre

Other (please specify below)

Please describe your specific support needs and goals:

Current Supports and Service Providers (if any):

8. AVAILABILITY & PREFERENCES

Preferred Days for Support (tick all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Times:

Morning (6am-12pm)

Afternoon (12pm-6pm)

Evening (6pm-10pm)

Flexible

Transport Arrangements:

Own transport

Public transport

Family/friend transport

Require transport support

9. INTERESTS, HOBBIES & GOALS

What are your interests and hobbies?

What are your goals? (What do you want to achieve with NDIS support?)

10. ADDITIONAL INFORMATION

How did you hear about Townsville Support Solutions?

Google search

Facebook/Social media

Friend/Family recommendation

NDIS planner/LAC

Support coordinator

Other: _________________________________

Cultural or Religious Considerations:

Any other information we should know:

11. CONSENT & DECLARATION

I consent to Townsville Support Solutions collecting, using, and disclosing my personal information for the purpose of providing NDIS support services.

I understand that my information will be kept confidential and only shared with relevant parties as required for my care and support.

I consent to Townsville Support Solutions contacting my GP, specialists, or other service providers as necessary for my support.

I understand that I can withdraw my consent at any time by contacting Townsville Support Solutions.

Participant Name (please print):

Date:

Participant/Guardian Signature:

If signed by guardian/representative:

Guardian/Representative Name:

Relationship to Participant:

NDIS PARTICIPANT INTAKE FORM