Optimum Health Solutions

NDIS Participant Intake Form

This form is designed to help us understand your specific needs and goals under the National Disability Insurance Scheme (NDIS). By providing detailed information about your medical history, lifestyle, and current health concerns, we can develop a personalised plan to support your well-being.

Please fill out the form thoroughly and accurately. Your responses will remain confidential and are essential for us to provide the best possible care and support. Thank you for choosing Optimum Health Solutions.

Name

Date Of Birth (Age)

Gender

Address

Phone

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

NDIS Plan Number

NDIS Plan Dates

Accepted NDIS Diagnosis

Are supporting reports available for above accepted NDIS diagnosis?

Supporting Reports

Goals of NDIS Plan - NDIS goals, as identified in your NDIS plan

How are the plan funds managed?

The email of who will be responsible for signing the service agreement

Plan management details: Contact name and email

Plan management details: Invoicing Email

Category for funds to be used

Service(s) Required:

Nature Of Enquiry

Type Of Assessment Required

Assessment needs: Please provide some more information regarding the needs of the assessment

Allocated Funding:

Allocated funding for assessment/therapy

Session Frequency:

Location of Service:

Alternative Location

Address of Group Home, School, Day Program or other location:

Education status (if applicable):

Please specify name of institution:

Support Coordinator Details: Name

Support Coordinator Details: Company

Support Coordinator Details: Phone

Support Coordinator Details: Email

Additional Medical History – both physical and mental health (including year of diagnosis)

Are supporting reports available for above additional medical conditions diagnosed?

Supporting Reports

Primary Language Used in everyday communication

Do they require an interpreter?

Form of Communication (please choose most appropriate)

Mobility Status Requirements (what mode does the Participant use)

Other:

Waitlist management

Regional-based Client Management: Quote One Off Assessment/Report as per price guide

Regional-based Client Management: Willing to engage telehealth sessions as appropriate?

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If you have any questions or need further clarification regarding our intake and referral process, please do not hesitate to contact our clinic.

REFerrers Hub

Whether you’re a new referrer or you’ve used our services before, the Optimum referrers hub has all your needs. With one click you can make enquiries, make referrals and check all of our clinics’ service capacities.