Care that comes to you!
First Name
Last Name
Gender MaleFemaleOther
Date of birth
Phone
Email
NDIS number
Fund type Plan managedSelf-managedNDIA managedOther
Address
Relationship to NDIS Participant:
Contact Number :
PARTICIPANT DETAILS:
AloneFamily/ PartnerSupported accommodationOther
If you have selected 'other', please specify
NDIS Plan Start Date:
NDIS Plan End Date:
Name
Organisation
Position
Contact Number:
Are you able to sign documents on behalf of the NDIS Participant?
YesNo
Primary Disability
Secondary Disability
Please fill details below…
Any risk of self-harm identified?
Any harm from others identified?
Any harm to others identified?
Are there any pets on the property?
Are there any firearms being stored on the property?
Is there any history or current use of drugs at this property?
Any risk that support staff need to know (If yes, please specify below)
Does the participant display any challenging behaviours? (If yes, please specify below)
Attach a copy of the NDIS plan
By checking, I agree to share the above onformation to Gippsland Total Care Pty Ltd, for assessment purposes
