Participant Intake Form

Welcome to the Life24 participant intake. Please complete the form below so we can learn about you and the support you need. Your information is kept private and secure, and will only be used to help us deliver the best possible support to you.

If you need assistance completing this form, please contact us and we’ll be happy to help.

"*" indicates required fields

Step 1 of 11

Company

This field is for validation purposes and should be left unchanged.

Section 1 — Participant Details

Participant Name*

First Last

Date of Birth*

Age*

Gender*

If Other, please specify below*

Street Address*

Suburb*

State*

Postcode*

Section 2 — Contact Information

Participant Phone Number*

Participant Email*

Emergency Phone Number*

Emergency Email Address*

Do you have a Parent / Guardian etc?*

Yes

Parent / Guardian etc — Emergency Contact Name*

First Last

Relationship to Participant*

Section 3 — NDIS Information

NDIS Number*

Plan Dates (e.g. 01/07/2026 — 30/06/2028)*

Account Management*

Plan Manager Details

Plan Manager Organisation*

Plan Manager Name*

First Last

Plan Manager Phone Number*

Plan Manager Email Address*

External Agencies Involved*

List all that may be relevant

Do you have a Support Coordinator?*

Yes

Support Coordinator Organisation*

Support Coordinator Name*

First Last

Support Coordinator Phone Number*

Support Coordinator Email Address*

Section 4 — Living Arrangements

Living Arrangements (tick all that apply)*

Alone

Family / Partner

Supported Accommodation

Other

If Other — please specify living arrangements*

Section 5 — Disabilities

Primary Diagnosis*

Secondary / Co-occurring Conditions*

Section 6 — Communication

Does the Participant understand everything that is said?*

Yes

How does the Participant communicate? (tick all that apply)*

Speech

Vocalizing / Noise

Gestures

Communication Aid

Signing

Facial Expressions

Writing Skills

Reading Skills

Interpreter Required

If interpreter required — please specify language*

Any other communication needs?*

Yes

If yes — please describe communication needs*

Section 7 — Medical Information

Is medication assistance required while receiving supports?*

Yes

Name of medication/s and what are they for*

Is the use of as-needed medication required while on supports?*

Yes

Name of as-needed medication/s and what are they for*

Are there any other medical conditions we should know about?*

Yes

If yes — what are they and how are they managed?*

Is the use of any other aides required? (e.g. vision, hearing, mobility)*

Yes

If yes — please specify aides required*

Does the Participant have Asthma?*

If yes, please provide a copy of their Asthma Management Plan

Yes

Asthma Management Plan*

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

Does the Participant have Epilepsy?*

If yes, please provide a copy of their Epilepsy Management Plan

Yes

Epilepsy Management Plan*

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

Does the Participant have Diabetes?*

If yes, please provide a copy of their Diabetes Management Plan

Yes

Diabetes Management Plan*

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

Does the Participant have Allergies?*

If yes, please provide a copy of their Anaphylaxis Management Plan

Yes

Allergy Management Plan*

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

Section 8 — Care Concerns

How does the Participant react to new Support Workers / Others?*

Please provide details about reactions to new workers*

Does the Participant have any fears?*

Yes

If yes — please specify fears*

Section 9 — Meal & Nutrition

Are any special aids required for eating or drinking?*

e.g. special cup, utensils

Yes

If yes — please specify eating/drinking aids*

Does the participant need assistance with meals / eating / drinking, or specially prepared food or beverages?*

Yes

If yes — please specify meal assistance required*

Please list any foods or beverages the Participant cannot have*

Section 10 — Physical Activity

What is the Participant’s current physical status?*

e.g. walks without aids, can swim, can lift objects — please be specific

Section 11 — Behavioural Concerns

Is the Participant likely to exhibit inappropriate behaviour?*

e.g. aggression, sexual or other

Yes

If yes — please specify behaviour*

Would this behaviour be directed toward self or others?*

Does the Participant have an object or sensory item they use?*

Yes

If yes — please specify sensory item and whether it will be used during supports*

Does the Participant have Behaviour Management?*

If yes, please provide a copy of their Behaviour Management Plan

Yes

Behaviour Management Plan*

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

Is the Participant likely to abscond?*

e.g. wander, run away or hide

Yes

If yes — please specify absconding behaviours*

Does the Participant have risk-taking behaviours?*

e.g. fire-lighting, playing with matches

Yes

If yes — please specify risk-taking behaviours*

Is the Participant likely to damage property?*

Yes

If yes — please specify property damage behaviour*

Is the Participant likely to steal or shoplift?*

Yes

If yes — please specify behaviour*

Is the Participant aware of dangers?*

e.g. stranger danger, animals, road dangers

Yes

If no — please specify awareness gaps*

Section 12 — Personal Care / Hygiene

Can Wash Hands*

Can Shower / Bath*

Can Wash / Rinse Own Hair*

Can Dry Themselves*

Can un/Dress Themselves*

Comb Hair*

Clean Teeth*

Shave Themselves*

Manage Menstruation*

Use Toilet*

Wipe Themselves*

Does the participant have bladder / bowel control?*

Yes

Is bladder / bowel assistance required?*

Yes

If yes — please specify assistance required*

Section 13 — Supports Required

Supports Required (tick all that apply)*

Community Access

Group Programs

Activity Based Travel

Yard Maintenance

Assistance with Self Care

Personal Care

Provider Travel

House Cleaning

Other

If Other — please specify support required*

Section 14 — Support Days / Times

Write in each day the times you require support. Write NA if you do not require support on a particular day.

Monday Support*

Tuesday Support*

Wednesday Support*

Thursday Support*

Friday Support*

Saturday Support*

Sunday Support*

Section 15 — General Comments

Comments / Feedback

Are there any other details you would like us to know?

Section 16 — Consent

Exchange of Information – I/we consent to Life24 Support Services collecting and sharing information about the participant with relevant third parties where necessary to coordinate or deliver supports. This information will only be shared on a need-to-know basis.*

Yes

Read more here >

Consent to Receive Services – I/we consent to the participant receiving support services provided by Life24 Support Services, including observation by other professionals or trainees with prior notice.*

Yes

Read more here >

Consent to Use Photos / Digital Recordings / Original Material – I/we consent to photos, videos, and digital recordings of the participant being captured and used for internal service delivery purposes and/or in Life24 Support Services publications and digital platforms.*

Yes

Ask Me

Read more here >

Information Services – I/we consent to receiving communications from Life24 Support Services including newsletters, event information, and service updates by email or post.*

Yes

Read more here >

Research Participation – I/we consent to receiving invitations to participate in research projects reviewed and approved by Life24 Support Services. Participation is always voluntary.*

Yes

Read more here >

Privacy & Your Information – I/we consent to Life24 Support Services collecting, storing, using, and disclosing personal and sensitive information about the participant in accordance with the Privacy Act 1988 (Cth) and the Life24 Support Services Privacy Policy.*

Yes

Read more here >

Section 17 — Signatures

Participant Name*

First Last

Parent / Guardian / Nominee Full Name*

First Last

Participant Signature*

Parent / Guardian / Nominee Signature*

Date

Participant Intake Form

Section 1 — Participant Details

Section 2 — Contact Information

Section 3 — NDIS Information

Plan Manager Details

Section 4 — Living Arrangements

Section 5 — Disabilities

Section 6 — Communication

Section 7 — Medical Information

Section 8 — Care Concerns

Section 9 — Meal & Nutrition

Section 10 — Physical Activity

Section 11 — Behavioural Concerns

Section 12 — Personal Care / Hygiene

Section 13 — Supports Required

Section 14 — Support Days / Times

Section 15 — General Comments

Section 16 — Consent

Section 17 — Signatures

Support Services

Personal Services

Company

Forms

Keep in Touch