Intake Form - Donum Dei

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Welcome

This form will take about 10-15 min to complete. We will endeavour to contact you as soon as possible to arrange your services.

I am completing this for:*

Myself (I am the client)

My Child (or somebody I care for)

My Client (I am a support coordinator/GP/Allied Health)

What services do you require from us?*

Support Coordination

Plan Management

Assist Personal Activities

Household Tasks

Community Access

Supported Independent Living (SIL), Short-term Accom (STA), Medium-term Accom (MTA)

Group/Centre Activities

Development-Life Skills

Early Childhood Supports

Access/Maintain Employment

Therapeutic Supports (Counselling, Physio, OT, Speech)

Client/Participant Details

This section is for the person who is going to receive the services ("Participant")

Participant Name*

First Last

Preferred Name

Participant's Phone*

Participant's Email*

Participant Location*

Street Address City State Zip Code

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Non-binary

Intersex

Transgender

Prefer not to say

Does the participant identify as an Aboriginal or Torres Strait Islander?

Yes

Unknown

Languages spoken at home?

Interpreter required?

Yes

Key Diagnosis / Relevant Medical History*

Key Goals*

Preference for service location*

Community

SDA / SIL House

Home

School/Kinder/Childcare

Telehealth (Online Consultation)

Other (Hospital etc)

Carer Details

This section is about you, the carer.

Carer Name*

First Last

Carer's Phone*

Carer's Email*

Relationship to Participant*

Same address as participant?*

Yes

Carer's Location*

Street Address City State Zip Code

Support Coordinator / GP / Allied Health Details

Name*

First Last

Position*

Phone*

Email*

Organisation name*

Preferred contact person for this client*

You

Client

Funding

Funding Source*

NDIS

Medicare

Private Health

Self Funded (Paying from your own pocket - Not NDIS)

Do you have a copy of your NDIS plan to upload?*

Yes

Upload a copy of your NDIS plan*

Max. file size: 128 MB.

Plan Start Date*

Day

Month

Year

Plan End Date*

Day

Month

Year

NDIS Number*

How are the funds manage*

Agency Managed

Self Managed

Plan Managed

Plan Manager Company*

Plan Manager Contact Person

Plan Manager Phone*

Plan Manager Email*

Do you have a copy of your Medicare plan to upload?*

Yes

Upload a copy of your Medicare plan*

Max. file size: 128 MB.

Medicare Number*

Medicare Card Reference Number*

Medicare Card Expiry Date*

Day

Month

Year

What Medicare plan do you have?*

Better Access to Mental Health

Chronic Disease Management Plan / EPC

Helping Children with Autism Medicare Plan

Better Start for Children with Disability

Allied Health Services For Indigenous Australians Who Have Had A Health Check

Referral Name*

Referral Provider Number*

Plan Start Date*

DD dash MM dash YYYY

Number of Sessions*

Please type your insurance provider*

Community Visits

Is there adequate on street parking close to the home?*

Are there any restrictions on the parking areas around home?*

Do you have pets? (Please ensure all pets are outside of therapy room or restrained)*

Is there adequate mobile reception?*

Is the room clean and free of clutter?*

Is the room adequately heated/cooled?*

Is the room well ventilated?*

Is working area adequately lit?*

Is there adequate seating and desks space available?*

Is there adequate space available for gross motor interventions?*

Are there smokers in the house? (Please refrain from smoking during the session)*

Has any aggression from the client / other occupants been reported?*

Does the client / other occupants have a psychiatric history?*

Does the client /other occupants have a history of alcohol or drug misuse?*

Is the behaviour of other adult/ family members felt to be appropriate?*

Does the client / other occupants smoke within the home?*

Are there any firearms on the property?*

Any comments?

Donum Dei reserve the right to deny community visits and treatment sessions should there pose a risk to our staff.

Behaviours of Concern

At times when participants are upset/ frustrated/ or unable to communicate their needs, they can exhibit behaviours of concern. Please be as honest as possible as this helps our staff to prepare for successful and engaging sessions.

Is there a current Behaviour Support Plan?*

Yes

What is the details of the Behaviour Support Practitioner?*

Please upload the Behaviour Support Plan*

Max. file size: 128 MB.

Any behaviours of concern?*

At times when some participants are upset/ frustrated/ or unable to communicate their needs, they can exhibit behaviours of concern. Identifying these behaviours of concerns will help our staff to help the participant better. Please tick any behaviour of concern that you can identify.

Biting (self or others)

Hitting

Smacking

Hair pulling

Kicking (objects or others)

Strangling

Forceful pushing

Head butting

Verbal aggression

Eye gouging

Spitting

Other behaviours

None

Other (please elaborate)

Has any aggression from the client / other occupants been reported?*

Does this client have a diagnosis of schizophrenia or history of psychosis?*

Please elaborate*

Is the participant on any medication and if so are they compliant with taking medication? Are there any instances of psychosis?*

Please elaborate*

We require another adult present during the home assessment. Please confirm that there is a caregiver, relative who is available to attend during a home visit.*

Please specify the care giver, relative or support worker who will attend the visit*

Has there been any history of physical or psychological violence or threats of violence towards others?*

Any trigger(s) for the above behaviours of concern? (If applicable)

Triggers can include mention of specific words, phrases, a particular toy or action. Please list in as much detail as possible:

How did you hear about us?

How did you hear about us?*

Google search

Facebook / Instagram

Family / Friend

Support Coordinator

Allied Health Practitioner

Plan Manager

Directory Websites

Other

Support Coordinator Name

Company Name

Practitioner Name

Company Name

GP Name

Clinic Name

Company Name

Please provide website address

CAPTCHA

Intake Form.

Welcome

Client/Participant Details

Carer Details

Support Coordinator / GP / Allied Health Details

Funding

Community Visits

Behaviours of Concern

How did you hear about us?