Step 1 of 13 7% 1. Details of ParticipantName* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of BirthSelect your Place of BirthAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweGender*Select your genderMaleFemalePrefer Not to AnswerPreferred Language*Interpreter Required?*Choose from the followingYesNoNDIS Number*Address Street Address City / Town State Zip Code Email* Contact Number*NDIS Plan Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NDIS End Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Plan Manager Name*Plan Manager Contact Number*Plan Manager Email*Emergency Contact Person Name*Relationship to NDIS participant:*Contact Number* 2. Living ArrangementSelect any one of the following*ChooseAloneFamily / PartnerSupported accommodationOtherPlease Specify* 3. Guardian Details (if applicable)NameDate of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home PhoneMobile PhoneWork PhoneEmail Address Address Street Address City / Town State Zip Code 4. Details of Individual Making ReferralName*Organization*PositionAddress Street Address City / Town State Zip Code Email* Phone* 5. Participant DiagnosisPrimary Diagnosis*Secondary Diagnosis* 6. Details of Services RequiredPlease fill details 7. Safety Information1. Any risk of self-harm identified*Select from the followingYesNoIf yes, please specify*2. Harm from others Identified*Select from the followingYesNoIf yes, please specify*3. Harm to others identified*Select from the followingYesNoIf yes, please specify*4. Any pets on the property*Select from the followingYesNoIf yes, please specify*5. Any firearms being stored in the property*Select from the followingYesNoIf yes, please specify*6. Any history or current of people using alcohol or drugs at the property*Select from the followingYesNoIf yes, please specify*7. Any risk that support staff need to know*Select from the followingYesNoIf yes, please specifyDate of Referral*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 8. Participant Risk Assessment8.a) CommunicationHearing OK*Select from the followingYesNoHazards identified & actions required*Speech OK*Select from the followingYesNoHazards identified & actions required*Able to write*Select from the followingYesNoHazards identified & actions required*English language skills*Select from the followingYesNoHazards identified & actions required* 8.b) CognitionClient willing to participate and assist in care*Select from the followingYesNoHazards identified & actions required*Oriented in time and place*Select from the followingYesNoHazards identified & actions required*Client able to accept direction and instruction*Select from the followingYesNoHazards identified & actions required*Short-term memory issues*Select from the followingYesNoHazards identified & actions required* 8.c) MobilityWalk unaided*Select from the followingYesNoHazards identified & actions required*Manages stairs unaided*Select from the followingYesNoHazards identified & actions required*Uses walking aid to walk*Select from the followingYesNoHazards identified & actions required*Uses self-propelled wheelchair*Select from the followingYesNoHazards identified & actions required*Uses electric wheelchair/ scooter*Select from the followingYesNoHazards identified & actions required*Transfers independently*Select from the followingYesNoHazards identified & actions required*Transfers with supervision*Select from the followingYesNoHazards identified & actions required*Transfers with hoist*Select from the followingYesNoHazards identified & actions required* 8.d) Personal Care Assistance RequiredBed mobility*Select from the followingYesNoHazards identified & actions required*Showering*Select from the followingYesNoHazards identified & actions required*Toileting*Select from the followingYesNoHazards identified & actions required*Grooming*Select from the followingYesNoHazards identified & actions required*Repositioning in bed*Select from the followingYesNoHazards identified & actions required*Repositioning in chair*Select from the followingYesNoHazards identified & actions required*Mouth care*Select from the followingYesNoHazards identified & actions required*Eating*Select from the followingYesNoHazards identified & actions required*Skin care*Select from the followingYesNoHazards identified & actions required* 8.e) Violence RiskPhysical aggression to support worker*Select from the followingYesNoHazards identified & actions required*Verbal aggression to support worker*Select from the followingYesNoHazards identified & actions required*Aggression to other clients*Select from the followingYesNoHazards identified & actions required*Aggression with/against objects*Select from the followingYesNoHazards identified & actions required*Self-harm*Select from the followingYesNoHazards identified & actions required*Substance abuse*Select from the followingYesNoHazards identified & actions required*Sexual abuse*Select from the followingYesNoHazards identified & actions required*Threats to staff in any way*Select from the followingYesNoHazards identified & actions required*Use of emotions to achieve goals*Select from the followingYesNoHazards identified & actions required* 9. Participant Consent SectionAuthentic Life Care will work closely with other agencies to coordinate the best support for you. This means your informed consent for the sharing of information will be sought and respected in all situations unless:* Select All ✓ We are obliged by law to disclose your information regardless of consent or otherwise ✓ It is unreasonable or impracticable to gain consent or consent has been refused ✓ The disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people I hereby acknowledge that Authentic Life Care has advised me of the following:* Select All ✓ Authentic Life Care Privacy and Confidentiality Policy and Procedure ✓ My right to access my personal information ✓ My right to withdraw my consent at any time Check the following box* ✓ I understand that the follow service(s) are recommended and relevant information about me may be forwarded to the agency(s) that provide these services, in order that I receive the best possible service: (Insert names of third parties as agreed with client, e.g. Home and Community Care (HACC), Aboriginal Health Worker, Youth Worker.)*Check the following* Select All ✓ I understand that Authentic Life Care must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached ✓ My worker has discussed with me how and why certain information about me may need to be provided to other service providers ✓ I understand the recommendations and I give my permission for the information to be shared with the people or agencies as detailed above Are you sure to submit your form?10. Client / Guardian Delclaration This iframe contains the logic required to handle Ajax powered Gravity Forms.
