Referral Date: Phone: Participant Profile: Date Of Birth: Marital Status: Australian Resident: YesNo Indigenous Status: AboriginalTorres Strait IslanderBothNeither Language at Home: Interpreter required: YesNo Next of Kin/Carer: Phone: Does the consumer have decision making assistance: YesNo Informal Decision Maker Areas of decision making? Public Trustee Areas of decision making? Power of Attorney Areas of decision making? Enduring Power of Attorney Areas of decision making? Adult or Appointed Guardian - Copy of order available YesNo Contact Details Areas of decision making? CONDITIONS Does the consumer have any physical health condition? YesNo Does the consumer have a mental health condition? YesNo Does consumer have any cognitive disability? YesNo Does the consumer have access to funding? YesNo Does the consumer currently have an Individual Funding package? YesNo Does the consumer have any behaviors of concern? YesNo Does the consumer have an approval for Restrictive Practices? YesNo Expiry Date Does the consumer have a Positive Behavioural Support Plan in place? YesNo Type of Accommodation: Own HomeRentingCaravanRetirement VillageBoarding HouseHostelOther give my consent for this Intake form to be passed on to the staff at PWD-Care. Where did you hear about us? GoogleSocial MediaAdsReferred By SomeoneOther Do you wish to receive mail outs from PWD-Care? YesNo SEND
