Client Intake NON Therapy Services

AUTISM ADVISORY AND SUPPORT SERVICE

Client Intake Form for NON Therapy Services

Please complete the intake form below indicating what service/group you are applying for.

Client Intake Form - NON Therapy Services

Notify

Service Selection

Assessments

Dungeons & Dragons

Support Coordination

Assessment Selection

Occupational Therapy

Speech Therapy

Psychology / ASD

Client: First Name

Client: Last Name

Clients Details

Clients Date of Birth

Client Contact Number

Client Email Address

Gender

Male

Female

Other

Clients Country of Birth

Languages Spoken at Home

Is the Client of Aboriginal or Torres Strait Islander Decent

Client Address

Address Line 1

City

State

Post Code

Country

Name of School / Preschool Client Attends

Year Attending

Do you have Support Coordination funding in your NDIS plan?

How much Support Coordination funding is remaining in your plan?

Funding Source

NDIS Management

Self Managed

Plan Managed

Agency Managed

N/A

Plan Managers Details

Have you or your nominee contacted your Planner or LAC to have a “Support Coordination Request for Service” triggered?

Yes

N/A for Assessments or D&D applicants

If no, please do so as this will make your onboarding much more efficient.

NDIS Plan.

Please upload your NDIS Plan to assist us with goal setting

Optional - Upload your NDIS Plan here

Choose File

Clients NDIS Number

Does the Client have a formal ASD diagnosis?

How does the Client Communicate?

Clients Medical Information

Parent / Guardian 1

Does Parent / Guardian 1 have authority to access and receive client information?

Parent / Guardian 1

Relationship to Client

Parent / Guardian 1 Date of Birth

Parent / Guardian 1 Country of Birth

Parent / Guardian 1 Contact Number

Parent / Guardian 1 Email Address

Preferred Method of Contact

Phone

Does Parent / Guardian 1 Require an Interpreter?

Yes

Does the Client and Parent / Guardian 1 live at the same address?

Yes

Address of Parent if different to Client

Address Line 1

Address Line 2

City

State

Zip Code

Country

Parent / Guardian 2

Does Parent / Guardian 2 have authority to access and receive client information?

Parent / Guardian 2

Relationship to Client

Parent / Guardian 2 Date of Birth

Parent / Guardian 2 Country

Does Parent / Guardian 2 Contact Number

Parent / Guardian 2 Email Address

Preferred Method of Contact

Phone

Does Parent / Guardian 2 Require an Interpreter?

Yes

Does the Client and Parent / Guardian 2 live at the same address?

Yes

First Name of Parent/Guardian at different address

Last Name of Parent/Guardian at different address

Address of Parent if different to Client

Address Line 1

Address Line 2

City

State

Zip Code

Country

Client Siblings

Sibling 1

Age

Additional Needs

Sibling 2

Age

Additional Needs

Sibling 3

Age

Additional Needs

Emergency Contacts

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Name

Emergency Contact Phone

How did you hear about Autism Advisory & Support Service?

I give authorisation to Autism Advisory & Support Service to speak with Third Party Entities.

Providing consent to speak to third party entities and authorising access to reports, enables AASS to provide individualised client supports. This can be in the form of requesting reports from other service providers, reading reports, providing progress reports and speaking to other therapists and organisations to assist with service delivery.

Without this consent, we are unable to provide services.

Do you give consent for information collection (collect, maintain, store and release my information for the purposes of reporting under the Commonwealth/State and Territory Disability Agreement).

Applications can not be processed without this consent.

Photographs/video may be used for educational & promotional purposes. [This includes replication on this website, printed materials and our social media accounts.] Do you give permission for photographs and or videos to be used of this client?

Yes

Only a Parent or Gurdian can sign this legal document on behalf of a participant.

Signature

Relationship to Client

I agree and understand that the above electronic signature is the legal equivalent of my manual/handwritten signature.

Radio Field

Yes

Autism Advisory and Support service NDIS provider number 4050000936

0 Shares

Client Intake NON Therapy Services

AUTISM ADVISORY AND SUPPORT SERVICE

Client Intake Form for NON Therapy Services

Explore

Get Started

Store

About

Our Values:

Client Intake NON Therapy Services

AUTISM ADVISORY AND SUPPORT SERVICE

Client Intake Form for NON Therapy Services

Explore

Get Started

Store

About

Our Values:

Start typing and press enter to search