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.英文表格，附中文解释。请填写参与者基本资料、NDIS 计划、需要的支持、时间安排和安全注意事项，方便我们评估下一步。提醒：请尽量用英文填写表格，方便 NDIA、plan manager 或相关机构识别和处理资料。提醒：請盡量用英文填寫表格，方便 NDIA、plan manager 或相關機構識別和處理資料。

Do not fill this out if you are human:

Participant Details 参与者基本资料

Basic identifying and communication information.填写参与者姓名、联系方式、地址和沟通偏好。

Full legal name 法律姓名

Preferred name 常用名 / 希望我们怎么称呼

Date of birth 出生日期

Home address 地址

Suburb / postcode 区名 / 邮编

Participant phone 参与者电话

Participant email 参与者邮箱

Preferred language 偏好语言

Communication needs or preferences 沟通需要或偏好

Examples: Prefers Mandarin, needs simple step-by-step instructions, family member assists with decisions, becomes anxious with sudden changes.例子：偏好普通话、需要一步一步说明、由家人协助决定、突然改变安排会焦虑。

NDIS And Funding Details NDIS 与付款资料

Plan and funding information used to confirm service eligibility and claiming pathway.填写 NDIS 号码、计划日期和管理方式，方便确认是否能提供服务和如何付款。

NDIS number NDIS 号码

Plan start date 计划开始日期

Plan end date 计划结束日期

Plan management type NDIS 管理方式

Plan manager details Plan manager 资料，如适用

Participant goals relevant to support 与支持相关的目标

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.例子：更有信心外出、维持个人照护习惯、提高家务独立性、安全参加预约、建立固定生活作息。

Contacts 联系人资料

Family, representative, support coordinator and emergency contact details.填写家人、代表、support coordinator 和紧急联系人。

Primary contact name 主要联系人姓名

Relationship 与参与者关系

Primary contact phone 主要联系人电话

Support coordinator Support coordinator 资料，如有

Emergency contact 紧急联系人

Emergency phone 紧急联系电话

Requested Supports 需要的支持服务

Select the supports being requested and add scheduling notes.选择需要的服务，并填写希望的时间和作息安排。

Personal care 个人照护 Household tasks 家务协助 Community access 社区参与 / 外出 Transport assistance 交通陪同 Meal preparation 备餐协助 Daily routine support 日常作息支持 Skill development 生活技能发展 Group or centre activities 小组或中心活动 Other 其他

Requested hours per week 每周大约需要小时数

Preferred start date 希望开始日期

Urgency 紧急程度

Preferred days, times and routine notes 希望服务日期、时间和作息说明

Health, Safety And Worker Matching 健康、安全和护工匹配

Information needed to assess whether support can be delivered safely.这些资料帮助我们判断服务是否能安全安排，并匹配合适的 support worker。

Disability, diagnosis or support context 残障、诊断或支持背景

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.例子：自闭症并适合固定作息支持、使用轮椅需要转移协助、心理社会残障并偏好平静沟通、日常生活需要提醒。

Mobility and transfers 行动能力和转移协助

Equipment used 使用的辅助器材

Medication prompts 是否需要服药提醒

Allergies or medical alerts 过敏或重要健康提醒

Behaviour, safety, home access or environmental notes 行为、安全、入屋或环境注意事项

Examples: Dog at home, limited parking, manual handling required, may become distressed in noisy environments, medication prompting only, worker needs to call before arriving.例子：家里有宠物、停车困难、需要 manual handling、吵闹环境会焦虑、只需要服药提醒、护工到达前需先致电。

Worker matching preferences 护工匹配偏好

Examples: Mandarin-speaking worker preferred, female worker preferred for personal care, calm and patient support style, experience with autism, comfortable supporting community outings.例子：偏好普通话护工、个人照护偏好女性护工、需要有耐心的支持风格、有自闭症经验、能陪同外出。

Documents And Consent 文件和同意

Record what has been provided and who Summer Home Care may contact.请勾选已提供的文件，并确认我们可以联系相关人员处理 intake 和服务安排。

NDIS plan NDIS 计划 Participant goals 参与者目标 Risk assessment 风险评估 Behaviour support plan 行为支持计划 Medication information 药物相关资料 Service agreement required 需要服务协议

Additional intake notes 其他补充说明

Internal Follow-Up 内部跟进，可留空

Optional notes for the Summer Home Care team. Participants and families can leave this section blank.此部分主要给 Summer Home Care 团队内部使用，参与者和家属可以不填写。

Intake completed by 填写人 / 工作人员

Intake date 填写日期

Next step 下一步

Follow-up notes 跟进备注

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.隐私说明：在您点击 Email to Summer Home Care 或 Print / Save PDF 之前，表格内容只留在您的设备上。紧急医疗或安全情况请拨打 000。