Intake form for under 18s

Personal details

Name *

Date of Birth *

Gender *

Text

Address *

Contact Number *

Email Address

NDIS Number

Emergency contact details

Name *

Contact Number *

Relationship to You *

Address *

Email Address *

Other information

What is your disability? *

Do you have any allergies? If so please provide details

Do you have any other relevant medical conditions? (asthma, epilepsy, diabetes, etc)

Do you have a Mental Health condition? If so please provide details

Are you required to take any medication? If so please provide details

Do you have a history of physical or verbal aggression? If so please provide details

Do you have any access requirements that we need to know about? (Speech devices/Physical needs)

Is there any other information you think we should know about yourself?

Parent/Guardian consent

I (parent/guardian full name) *

give my permission for (applicant's full name) *

to participate in individualised services provided by Australian Inclusion Network.

I understand that for the service to be successful I must also commit to working collaboratively with Inclusion WA staff. This includes being available in person for meetings and by phone or email to discuss the details of my child’s services.

I also give permission for: (please tick all that apply)

I understand that I give my permission as parent/guardian for the applicant to participate in individualised services provided by Australian Inclusion Network. services are designed for my child to establish sustainable, independent and on-going participation in an activity or skill relating to a goal. For this to occur my child and their support network will need to work together to address time commitments, transport and financial requirements.

I agree

Disclaimer:
Please be aware that all the information provided in this form is essential in assisting us with the application and subsequent processes. It is therefore imperative that all areas of the form are addressed. Inclusion WA is not responsible for any incidents that may arise due to insufficient information provided on this form. Any additional information that could affect our capacity to work with the applicant should also be provided as an addendum to this application.

Closure of Australian Inclusion Network

Personal details

Emergency contact details

Other information

Parent/Guardian consent