General Info

Today's Date:

• Participant Name:

• Participant DOB:

Address:

• My preferred contact method:

• Name of Enquirer:

• My preferred emails:

• Enquirers Contact #:

How is Enquirer related:
ATSI Information:Aboriginal but not Torres Strait Islander originTorres Strait Islander but not Aboriginal originBoth Aboriginal and Torres Strait Islander originNeither Aboriginal or Torres Strait Islander originPrefer not to answer

Which services are you interested in?

NDIA Funding Info

NDIS Plan No:

• Plan Start Date:

• Plan End Date:

How is Funding Managed:Self-ManagedFin Plan ManNDIA Agency
Which of the following funds are available for use in your plan?
Are you happy to provide a copy of the Plan?YesNo
Note: Providing your plan is not essential but is very helpful

Personal Care and Mobility Support RequirementsAssistance with toiletingAssistance with feeding (PEG feed)Assistance with mobilitySupport with managing feminine hygieneWheelchair or mobility aidBowel or bladder incontinenceAssistance with transfersOther requirements of care
Further information:

Dietary Requirements

I have the following allergies/intolerances and my favourite food it...
No dietary requirements
Vegetarian
Vegan
I am allergic to(please list foods)
I am unable to eat (sensory/intolerances)
My favourite food is
AICSs can assist me during meal times by……
I can identify what foods are safe for me to eat (if required due to allergy or dietary requirements).If I have a food allergy, I have provided AICSs with a management plan.If required I will bring any medications to assist me with my allergy and have completed the relevant medication forms.I prefer to provide my own food and will do so.

Mental Health

I have/experience...
DepressionAnxietyPsychosisSchizophreniaBipolarOther

Please supply relevant management plans.

I receive medical support to assist me and AICS has a copy of any relevant management plans to help me manage

Physical Health

I have...
DiabetesSleep ApnoeaEpilepsyAllergies to ………………………AsthmaDietary NeedsVisual ImpairmentBlood DisordersCognitive ImpairmentHearing ImpairmentHeart ConditionsOther
AICS can help me manage this by…….

To help our us understand you better, please fill the below:

I have provided AICSs with any relevant behaviour plans for assisting me when required.