PO Box 809 Redbank Plains Qld 4301
info@pivotalconnect.com.au
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Our Approach
Our Services
Support Coordination
Psychosocial Recovery Coaching
Community Access & Transportation
Respite, Accommodation (STR/MTA)
Personal Training
Cleaning & Yard Maintenance
Home Care & Daily Living
Individual and Community Support
CALD, Maori and Pasefika Supports
Social Work
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Blogs
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Career
(07) 3063 3261
Participant Intake Form
PARTICIPANT DETAILS
First Name
(Required)
Last Name
(Required)
Gender
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Address
(Required)
Suburb
(Required)
Postcode
(Required)
State
(Required)
Contact Number
(Required)
Email address
(Required)
Preferred method of communication
Phone
SMS
Email
Mail
NDIS Number
NDIS Funding Type
Self Managed
Plan Managed
NDIA Managed
If applicable, Plan Manager/Plan nominee details
Name
Organisation
Email
Contact Number
Plan start date
MM slash DD slash YYYY
Plan end date
MM slash DD slash YYYY
PERSONAL DETAILS
Aboriginal or Torres Strait Islander descent?
Yes
No
Living Situation
Own home (living alone)
Own home (living with family)
Living in supported accommodation
Temporary (relatives, friends or other)
At risk
Homeless
Other
Do you have a current Behavioural Support Plan?
Yes
No
Primary Formal Diagnosis
Secondary Formal Diagnosis
Are there any legal issues that may affect our service? If applicable, please provide details
Other relevant information
REPRESENTATIVE OR EMERGENCY CONTACT DETAILS
CONTACT 1
Advocate
Guardian
Emergency Contact
Parent
Support Person
Plan Nominee
Other
Name
Relationship to Client
Address
Contact Number
Email
Advocacy Form Supplied?:
Yes
No
CONTACT 2
Advocate
Guardian
Emergency Contact
Parent
Support Person
Plan Nominee
Other
Name
Relationship to Client
Address
Contact Number
Email
Advocacy Form Supplied?
Yes
No
COMMUNICATION
Type
Verbal
Non-Verbal
Communication aids required
Other
Languages Spoken
English
Other
Is an Interpreter required?
No
Language
Hearing impaired
PHYSICAL HEALTH
PHYSICAL HEALTH
Asthma
Diabetes
Epilepsy
Heart Conditions
Visual Impairment
Hearing Impairment
Cognitive Impairment
Blood Disorders
Sleep Apnoea
Other
Medications
If applicable, please list
I would like assistance with managing this by
MENTAL HEALTH
Mental Health
Depression
Anxiety
Post-traumatic stress disorder (PTSD)
Bipolar
Psychosis
Schizophrenia
Obsessive compulsive disorder (OCD)
Mood Disorder
Other
Medications
If applicable, please list
History of hospital admission?
Yes (please provide further details)
No
I would like assistance with managing this by
DIETARY REQUIREMENTS
Any dietary requirements
Yes
No
Vegetarian
Yes
No
Vegan
Yes
No
Dairy free
Yes
No
Gluten free
Yes
No
Allergies (If applicable, please list)
I do not like to eat (please list)
My favorite food is
PRACTICAL SUPPORT NEEDS
I require assistance with:
Mobility
Independent
Walking Stick
Manual Hoist
Assist
Walking Frame
Shower Chair
Other
Personal Care
Shower/Bath
Toileting
Grooming
Dressing
Other
What Pivotal Connect services do you require?
In-Home and Community Supports
1. Assistance in Coordinating or Managing Life Stages, Transitions and Supports
2. Daily personal Activities
3. Assistance with Travel/Transport Arrangements
4. Innovative Community Participation
5. Development of Daily Living and Life Skills
6. Household Tasks
7. Participation in Community, Social and Civic Activities
Supported Independent Living/Respite Care/Group
1. Assistance with Daily Life Tasks in a Group or Shared Living Arrangement
2. Group and Centre Based Activities
Employment related supports
1. Assistance to Access and Maintain Employment or Higher Education
2. Specialised Supported Employment
Professional Registration Groups
1. Implementing Behaviour Support Plans
2. Exercise Physiology and personal Training
3. Specialised Support Coordination
Specialist Disability Accommodation Product Related Groups
1. Assistive Products for Personal Care and Safety
2. Personal Mobile Equipment
Pivotal Connect can assist me by ….
YOUR PREFERENCES
Do you have specific preferences when matching our staff with you?
Gender
Male
Female
No preference
Age Group
Culture/Religion/Ethnicity
Languages Spoken
Personality characteristics
Specific needs, skills or knowledge required?
Specific training that may be required to provide services and support to you?
Is there anything else you would like us to know about you that is important for how we provide our services to you?
What are your goals, expectations and desired outcomes when receiving our services?
What are your goals for the next 12 months?
CONSENT AND ACKNOWLEDGEMENT
By signing below, I acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.
Do you consent to participating in and use of:
Participating in audits of our business by the NDIS Commission and its auditors
Photos for Social Media
Photos for our website
None of the above
Signed by the Client
Date
MM slash DD slash YYYY
Name (please print)
Signed by the Representative
Date
MM slash DD slash YYYY
Name (please print)
Signed for and on behalf of Pivotal Connect ABN 32 674 328 182:
Date
MM slash DD slash YYYY
Name (please print)
Looking for the NDIS referral form?
Download & email to:
info@pivotalconnect.com.au
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