Summer Home Care

Participant Intake Form

English form with Chinese guide notes. Use this form to share key details before Summer Home Care confirms NDIS support, service agreement requirements, worker matching and safety considerations.鑻辨枃琛ㄦ牸锛岄檮涓枃瑙ｉ噴銆傝濉啓鍙備笌鑰呭熀鏈祫鏂欍€丯DIS 璁″垝銆侀渶瑕佺殑鏀寔銆佹椂闂村畨鎺掑拰瀹夊叏娉ㄦ剰浜嬮」锛屾柟渚挎垜浠瘎浼颁笅涓€姝ャ€?/span>鎻愰啋锛氳灏介噺鐢ㄨ嫳鏂囧～鍐欒〃鏍硷紝鏂逛究 NDIA銆乸lan manager 鎴栫浉鍏虫満鏋勮瘑鍒拰澶勭悊璧勬枡銆?/span>鎻愰啋锛氳珛鐩￠噺鐢ㄨ嫳鏂囧～瀵〃鏍硷紝鏂逛究 NDIA銆乸lan manager 鎴栫浉闂滄妲嬭瓨鍒ュ拰铏曠悊璩囨枡銆?/span>

Do not fill this out if you are human:

Participant Details 鍙備笌鑰呭熀鏈祫鏂?/span>

Basic identifying and communication information.濉啓鍙備笌鑰呭鍚嶃€佽仈绯绘柟寮忋€佸湴鍧€鍜屾矡閫氬亸濂姐€?/span>

Full legal name 娉曞緥濮撳悕

Preferred name 甯哥敤鍚?/ 甯屾湜鎴戜滑鎬庝箞绉板懠

Date of birth 鍑虹敓鏃ユ湡

Home address 浣忓潃

Suburb / postcode 鍖哄悕 / 閭紪

Participant phone 鍙備笌鑰呯數璇?/span>

Participant email 鍙備笌鑰呴偖绠?/span>

Preferred language 鍋忓ソ璇█

Communication needs or preferences 娌熼€氶渶瑕佹垨鍋忓ソ

Examples: Prefers Mandarin, needs simple step-by-step instructions, family member assists with decisions, becomes anxious with sudden changes.渚嬪瓙锛氬亸濂芥櫘閫氳瘽銆侀渶瑕佷竴姝ヤ竴姝ヨ鏄庛€佺敱瀹朵汉鍗忓姪鍐冲畾銆佺獊鐒舵敼鍙樺畨鎺掍細鐒﹁檻銆?/span>

NDIS And Funding Details NDIS 涓庝粯娆捐祫鏂?/span>

Plan and funding information used to confirm service eligibility and claiming pathway.濉啓 NDIS 鍙风爜銆佽鍒掓棩鏈熷拰绠＄悊鏂瑰紡锛屾柟渚跨‘璁ゆ槸鍚﹁兘鎻愪緵鏈嶅姟鍜屽浣曚粯娆俱€?/span>

NDIS number NDIS 鍙风爜

Plan start date 璁″垝寮€濮嬫棩鏈?/span>

Plan end date 璁″垝缁撴潫鏃ユ湡

Plan management type NDIS 绠＄悊鏂瑰紡

Plan manager details Plan manager 璧勬枡锛屽閫傜敤

Participant goals relevant to support 涓庢敮鎸佺浉鍏崇殑鐩爣

Examples: Build confidence going into the community, maintain a personal care routine, improve independence with household tasks, attend appointments safely, keep a consistent weekly routine.渚嬪瓙锛氭洿鏈変俊蹇冨鍑恒€佺淮鎸佷釜浜虹収鎶や範鎯€佹彁楂樺鍔＄嫭绔嬫€с€佸畨鍏ㄥ弬鍔犻绾︺€佸缓绔嬪浐瀹氱敓娲讳綔鎭€?/span>

Contacts 鑱旂郴浜鸿祫鏂?/span>

Family, representative, support coordinator and emergency contact details.濉啓瀹朵汉銆佷唬琛ㄣ€乻upport coordinator 鍜岀揣鎬ヨ仈绯讳汉銆?/span>

Primary contact name 涓昏鑱旂郴浜哄鍚?/span>

Relationship 涓庡弬涓庤€呭叧绯?/span>

Primary contact phone 涓昏鑱旂郴浜虹數璇?/span>

Support coordinator 鏀寔鍗忚皟鍛樿祫鏂欙紝濡傛湁

Emergency contact 绱ф€ヨ仈绯讳汉

Emergency phone 绱ф€ヨ仈绯荤數璇?/span>

Requested Supports 闇€瑕佺殑鏀寔鏈嶅姟

Select the supports being requested and add scheduling notes.閫夋嫨闇€瑕佺殑鏈嶅姟锛屽苟濉啓甯屾湜鐨勬椂闂村拰浣滄伅瀹夋帓銆?/span>

Personal care 涓汉鐓ф姢 Household tasks 瀹跺姟鍗忓姪 Community access 绀惧尯鍙備笌 / 澶栧嚭 Transport assistance 浜ら€氶櫔鍚?/span> Meal preparation 澶囬鍗忓姪 Daily routine support 鏃ュ父浣滄伅鏀寔 Skill development 鐢熸椿鎶€鑳藉彂灞?/span> Group or centre activities 灏忕粍鎴栦腑蹇冩椿鍔?/span> Other 鍏朵粬

Requested hours per week 姣忓懆澶х害闇€瑕佸皬鏃舵暟

Preferred start date 甯屾湜寮€濮嬫棩鏈?/span>

Urgency 绱ф€ョ▼搴?/span>

Preferred days, times and routine notes 甯屾湜鏈嶅姟鏃ユ湡銆佹椂闂村拰浣滄伅璇存槑

Health, Safety And Worker Matching 鍋ュ悍銆佸畨鍏ㄥ拰鎶ゅ伐鍖归厤

Information needed to assess whether support can be delivered safely.杩欎簺璧勬枡甯姪鎴戜滑鍒ゆ柇鏈嶅姟鏄惁鑳藉畨鍏ㄥ畨鎺掞紝骞跺尮閰嶅悎閫傜殑 support worker銆?/span>

Disability, diagnosis or support context 娈嬮殰銆佽瘖鏂垨鏀寔鑳屾櫙

Examples: Participant has autism and benefits from routine-based support, uses a wheelchair and needs transfer assistance, has psychosocial disability and prefers calm communication, needs prompting for daily living tasks.渚嬪瓙锛氳嚜闂棁骞堕€傚悎鍥哄畾浣滄伅鏀寔銆佷娇鐢ㄨ疆妞呴渶瑕佽浆绉诲崗鍔┿€佸績鐞嗙ぞ浼氭畫闅滃苟鍋忓ソ骞抽潤娌熼€氥€佹棩甯哥敓娲婚渶瑕佹彁閱掋€?/span>

Mobility and transfers 琛屽姩鑳藉姏鍜岃浆绉诲崗鍔?/span>

Equipment used 浣跨敤鐨勮緟鍔╁櫒鏉?/span>

Medication prompts 鏄惁闇€瑕佹湇鑽彁閱?/span>

Allergies or medical alerts 杩囨晱鎴栭噸瑕佸仴搴锋彁閱?/span>

Behaviour, safety, home access or environmental notes 琛屼负銆佸畨鍏ㄣ€佸叆灞嬫垨鐜娉ㄦ剰浜嬮」

Examples: Dog at home, limited parking, manual handling required, may become distressed in noisy environments, medication prompting only, worker needs to call before arriving.渚嬪瓙锛氬閲屾湁鐙椼€佸仠杞﹀洶闅俱€侀渶瑕?manual handling銆佸惖闂圭幆澧冧細鐒﹁檻銆佸彧闇€瑕佹湇鑽彁閱掋€佹姢宸ュ埌杈惧墠闇€鍏堣嚧鐢点€?/span>

Worker matching preferences 鎶ゅ伐鍖归厤鍋忓ソ

Examples: Mandarin-speaking worker preferred, female worker preferred for personal care, calm and patient support style, experience with autism, comfortable supporting community outings.渚嬪瓙锛氬亸濂芥櫘閫氳瘽鎶ゅ伐銆佷釜浜虹収鎶ゅ亸濂藉コ鎬ф姢宸ャ€侀渶瑕佹湁鑰愬績鐨勬敮鎸侀鏍笺€佹湁鑷棴鐥囩粡楠屻€佽兘闄悓澶栧嚭銆?/span>

Documents And Consent 鏂囦欢鍜屽悓鎰?/span>

Record what has been provided and who Summer Home Care may contact.璇峰嬀閫夊凡鎻愪緵鐨勬枃浠讹紝骞剁‘璁ゆ垜浠彲浠ヨ仈绯荤浉鍏充汉鍛樺鐞?intake 鍜屾湇鍔″畨鎺掋€?/span>

NDIS plan NDIS 璁″垝 Participant goals 鍙備笌鑰呯洰鏍?/span> Risk assessment 椋庨櫓璇勪及 Behaviour support plan 琛屼负鏀寔璁″垝 Medication information 鑽墿鐩稿叧璧勬枡 Service agreement required 闇€瑕佹湇鍔″崗璁?/span>

Additional intake notes 鍏朵粬琛ュ厖璇存槑

Internal Follow-Up 鍐呴儴璺熻繘锛屽彲鐣欑┖

Optional notes for the Summer Home Care team. Participants and families can leave this section blank.姝ら儴鍒嗕富瑕佺粰 Summer Home Care 鍥㈤槦鍐呴儴浣跨敤锛屽弬涓庤€呭拰瀹跺睘鍙互涓嶅～鍐欍€?/span>

Intake completed by 濉啓浜?/ 宸ヤ綔浜哄憳

Intake date 濉啓鏃ユ湡

Next step 涓嬩竴姝?/span>

Follow-up notes 璺熻繘澶囨敞

Privacy note: this form stays on your device until you choose Email to Summer Home Care or Print / Save PDF. Please do not use this form for emergencies. For urgent medical or safety concerns, call 000.闅愮璇存槑锛氬湪鎮ㄧ偣鍑?Email to Summer Home Care 鎴?Print / Save PDF 涔嬪墠锛岃〃鏍煎唴瀹瑰彧鐣欏湪鎮ㄧ殑璁惧涓娿€傜揣鎬ュ尰鐤楁垨瀹夊叏鎯呭喌璇锋嫧鎵?000銆?/span>