Intake Form

Referring a Participant, Client or Patient to Absolute Care & Health

"*" indicates required fields

If you have any questions, please call us on 03 9978 9140.

Programme type*

Participant ref number*

Client ref number

How is the plan managed financially?*

Plan management organisation name*

Plan management contact name*

Plan management contact phone*

Plan start date

Plan end date

Workcover Insurer*

Workcover insurer contact name*

Workcover insurer contact phone*

Please provide programme / funding details*

Referrer details

Referrer type*

Organisation*

Contact*

Referrer email*

Referrer phone*

Client / Participant details

Salutation*

First name*

Last name*

Email*

Phone

Date of birth*

Gender*

Street address line 1*

Street address line 2

Suburb*

State*

Postcode*

Primary contact / plan nominee (if applicable)

Primary contact name

Primary contact relationship

Primary contact email

Primary contact phone

Disability information

Primary disability*

Secondary disability

Primary disability other

Secondary disability other

We are not an accredited Mental Health organisation, but are able to provide disability supports that are not clinical in nature and that focus on the Participant’s functional ability. We are mindful that it is vital that support workers have appropriate experience and skills when supporting a Participant with a psycho-social diagnosis. Therefore we consider each situation individually through an initial intake assessment with one of our Registered Nurses in order to help us determine whether we have suitable support workers available.

Does the participant have a Behavioural Support Plan (BSP) or is there funding for Behavioural Supports in their Plan?*

For individual supports (disability support worker) we are not able to accept participants with a Behavioural Support Plan because we are not set up to meet the additional requirements for providers when a BSP is in place. For nursing services, we can accept participants with a BSP.

Are there any behaviours of concern or identified risks?*

Please provide details

Service requirements

Core supports

Assistance with daily life*

Assistance with social and community participation*

Transport*

Nursing care*

What is the maximum budget allocated in the plan for the core supports to be provided by us?

Personal Care*

Meal preparation*

Shopping & community access*

Companionship*

Cleaning, domestic support*

Nursing*

Capacity building supports

Improved daily living skills*

Increased social and community participation*

Nursing care*

What is the maximum budget allocated in the plan for the capacity building supports to be provided by us?

Nursing supports

Type of nursing care required*

Other nursing care type*

Presenting issues

Co-morbidities

Does the participant have high intensity funding?*

Are there any support worker / carer preferences or specific skills requirements? E.g specific language, cultural considerations or other preferences.

Please provide a brief overview of goals, care / support requirements and any other relevant information*

What days and times is support / care required or if unknown approx. how many hours per week?*

Minimum shift lengths may apply

Preferred service start date*

Are Public Holidays required?

OHS assessment

Any pets in the home?*

Any smokers in the home?*

Is anyone in or around the home that could be considered a security risk?*

Consider IV drug user, alcohol abuse, history of violence or abuse.

Please provide risk details*

Are there any weapons or firearms on the premises?*

Is it a multi-story flat?*

Is street parking available?*

What floor is it on?*

Will we need an access code to enter the property? If so, we will need this before commencing services.

Is the property in a known fire danger area?*

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Provide details of access code, if required, to enter the property

Please provide any additional information

Are there any allied health, psych assessments, care/support plans or other relevant reports? Please attach here

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