AJH Intake Form - Existing Participant

Exisiting Participant Information

Participant's First Name

Participant's Last Name

Have any of the following participant details changed? Please select all that apply

Address
Contact DetailsPlan datesContactsNew Service

Participant's Address

Address Line 1

Address Line 2

City

State

Postcode

Participant's Contact Details

Mobile Phone Number

Home Phone Number

Preferred Method of Contact

Participant's Contacts

Do you [the participant] have any of the following? (Please select all that apply)

Formal Guardian	Informal Guardian	NDIS Plan Nominee
Support Coordinator	Other

Formal Guardian Contact Details

First Name

Last Name

Phone

Informal Guardian Contact Details

First Name

Last Name

Phone

Plan Nominee Contact Details

First Name

Last Name

Phone

Support Coordinator Contact Details

First Name

Last Name

Phone

Other Contact Details

First Name

Last Name

Phone

Relationship to Participant

Referral Information

NDIS Plan Dates

Start Date

End Date

Service/s Required (Select all that apply for this referral)

Assessment and ReportCB - Improved Relationships (Behaviour Support)Specialist Support CoordinationSupport Coordination (Level 2)
Occupational TherapySupported Independent Living/Independent Living OptionsDay Program Services (Sunshine Coast only)

Please attach a copy of your NDIS Plan (Required for Support Coordination referrals but it's ok if you don't have it handy right now - you can send it to us by email intake@ajh.org.au later)

Please attach a copy of your NDIS Plan goals. (If you'd like to attach the whole plan, that's ok too). If you don't have them handy right now, you can send it to us by email intake@ajh.org.au later.

Please attach a copy of your NDIS Plan Budget. If you don't have it handy right now, you can send it to us by email intake@ajh.org.au later.

Budget that the work will be paid from

Core
Capacity Building - Improved Daily Living
Capacity Building - Improved Relationships
Capacity Building - Support CoordinationCapacity Building - Improved Health and WellbeingEarly Childhood Early InterventionSelect all that apply

Budget Information

Proposed amount (core)

Proposed amount (CB-Support Coordination)

Proposed amount (CB-IR Specialist Behaviour Support)

Proposed amount (CB-IR Plan writing and training)

Proposed amount (CB-IR Individual Social Skills Development)

Proposed amount (CB-IDL)

Proposed amount (ECEI)

Proposed amount (CB-IHW)

Finance Information

How is the Participant's NDIS Budget managed?

Agency (NDIA)
Self ManagedPlan Managed

Plan Manager Details

Plan Manager Name

Email for Invoicing

Invoicing Details

Name

Email for Invoicing

Date work is required to be completed by (if applicable)

Date

Please provide a date if the work being requested is for review purposes

Service Agreement

How would you like to receive the service agreement?

Receive the Service Agreement by email through an online signing platform
Receive the Service Agreement as a pdf by email to be printed for signing and the scanned document returned by email

Please provide name and contact email

Would you like to receive a PDF version of the Service Agreement by email for review prior to the first appointment?

YesNo

Who should the copy of the Service Agreement be sent to for review? (Select all that apply and please make sure email contact has previous been provided for the nominated party or changed above if applicable)

Participant	Plan Nominee	Informal Guardian
Formal Guardian	Support Coordinator	Other

Please provide name and contact email

Reason for referral

Please provide as much information as possible including hoped for outcomes of referral, linked participant goals for the referral, relevant diagnoses, dates work is required to commence and/or be completed by.

Referrer Details

First Name

Last Name

Phone

Relationship to Participant

Further Comments