NDIS Intake Form | BBDR- Byron Bay Detox Retreats New South Wales

INTAKE FORM

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PERSONAL DETAILS

Full Name

Date of Birth

Phone Number

Post Code

NDIS Number

Preferred start date for respite

Preferred end date for respite

If other, who are you in relation to the patient?

PLAN MANAGEMENT

If self-managed write SELF in the following fields.

Plan Manager Name

Plan Manager Email

Plan Manager Phone Number

PLEASE PROVIDE DETAILED INFORMATION ABOUT YOUR NDIS DIAGNOSIS

Primary Diagnosis

Secondary Diagnosis

Other Medical Conditions

Do you have any legal issues that may affect services? If no, please write N/A. If yes, please specify.

GOALS

What is your ultimate goal from your respite?

Please list any interests and activities that you would like to do during your respite.

Do you want skill building? If no, please write N/A, If yes, please tell us what you are wanting.

Anything else we need to know to support you during your respite?

SUPPORT COORDINATOR

If no, please write N/A. If yes, please answer.

Support Coordinator Name

Support Coordinator Company Name

Support Coordinator Email

Support Coordinator Phone Number

SUPPORT WORKER

Your support worker is there to:

Provide support for any personal care needs you have
Provide general transport while you are here
Provide transport to & from activities
Take you out on day trips so you can explore the local area
Support you with any extra mobility requirements you have

If you're coming with a Support Worker please provide your Support Workers Details (Name/Phone/Email), so we can liaise directly with them about the documentation we require. Or please give them our details and ask them to contact us.

If you require us to provide your support worker, how many hours a day would you like a support worker?

How many bedrooms do you require?

ABOUT ME

I am independent in my daily life, please use the numbers to indicate following in the boxes.

1 - Independent

2 - Need Prompting

3 - Need a little assistance

4 - Need full assistance

Shower Myself

Toilet Myself

Dress Myself

Make myself a meal

Take medication

Wash dishes

Do my laundry

Use technology

Interact with the community and make friends easily

Express my feelings

Please rate your average stress level on a scale of 1 to 10 (10 being the highest stress level)

Please rate your average energy level on a scale of 1 to 10 (10 being the highest stress level)

What time of your day is your energy at its highest?

What time of the day is your energy at its lowest?

MOBILITY

Use the dropdown to select an option below:

LOW: Good to Fair Mobility
I am able to get up start my day without the use of aids, I can walk short distances.

MEDIUM: I use Mobility Aids
I use wheelchairs or walkers occasionally.

HIGH: High Risk of Falling

I've had multiple falls in the last 6 months or use a wheelchair full-time, or I get seizures & tremors.

If you use/require any equipment during your program, please provide details (e.g. shower chair, commode etc.)

If you require assistance using any equipment, please provide details.

If yes, please specify (E.g: care plan, diabetes plan, epilepsy plan, mealtime management plan)

Please provide further details that would assist us in understanding your needs and your current daily support requirement. The more details you provide will assist us to provide a better customized program for you.

Please list all known allergies or intolerances including food, environmental, medical, chemical

List your Likes / Dislikes /Triggers

Are there any cultural considerations that you would like to share with us?

TRAVEL

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Email

Emergency Contact Phone Number

I confirm that the information I have provided on this form is true, complete, and accurate.

I acknowledge that I have read and understood the Byron Bay Detox Retreats Privacy Policy and give informed consent for the sharing of personal information in line with the policy.

COMPLETED BY

Type your full name below.

Participant/Participant's Representative Name

REJUVENATE YOUR MIND, BODY, AND SPIRIT • ENQUIRE TODAY

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