Intake Form

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Welcome

This form will take about 10-15 min to complete. Our new and improved online Intake Form is the easiest way to begin your journey with us. If you need any assistance with filling out the form, we are available to help during AEST Business Hours on 1800 767 489. Once we receive the completed Intake Form, we will endeavour to contact you as soon as possible to arrange your services.

This form is for:*

My Child (or somebody I care for)

Myself (I am the client)

My Client (I am a support coordinator/GP/Allied Health)

What services do you need?*

Occupational Therapy

Allied Health Assistant (AHA)

SIL and Short-term Accommodation (STA)

Specialised Disability Accommodation (SDA)

Support Worker / Community Services

Client/Participant Details

This section is for the person who is going to receive the services ("Participant")

Participant's Name*

First Last

Preferred Name

Preferred Pronoun*

Participant's Phone Number*

Participant's Email Address*

Participant's Location*

Street Address City State Postcode

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Non-binary

Intersex

Transgender

Prefer not to say

Does the participant identify as an Aboriginal or Torres Strait Islander?

Yes

Unknown

Languages spoken at home?

Is an interpreter required?

Yes

Current Diagnosis & Relevant Medical History*

Current Goals*

Preference for service location*

North Clinic (Bundoora VIC 3083)

East Clinic (Blackburn VIC 3130)

Home

School/Kinder/Childcare

Telehealth (Online Consultation)

Other (Hospital / SIL / Group Home / etc)

Carer's Details

This section is about you, the carer.

Carer's Name*

First Last

Carer's Phone Number*

Carer's Email Address*

What is your relationship with the participant?*

Do you have the same address as the participant?*

Yes

Carer's Location*

Street Address City State Postcode

Support Coordinator / GP / Allied Health Details

Name*

First Last

Position*

Email*

Phone*

Organisation Name*

Preferred contact person for this client*

Support Coordinator / GP / Allied Health

Client

Client Phone Number*

Client Email Address*

Funding

Funding Source*

NDIS

Medicare

Private Health Insurance

Self Funded (Paying from your own pocket - Not NDIS)

Do you have a copy of your NDIS plan to upload?*

Yes

Upload a copy of your NDIS plan*

Max. file size: 512 MB.

Plan Start Date*

Day

Month

Year

Plan End Date*

Day

Month

Year

NDIS Number*

How are the funds managed*

Agency Managed

Plan Managed

Self Managed

Plan Manager Company*

Plan Manager Contact Person

Plan Manager Phone Number*

Plan Manager Email Address*

Do you have a copy of your Medicare plan to upload?*

Yes

Upload a copy of your Medicare plan*

Max. file size: 512 MB.

Medicare Number*

Medicare Card Reference Number*

Medicare Card Expiry Date*

Day

Month

Year

What Medicare plan do you have?*

Better Access to Mental Health

Chronic Disease Management Plan / EPC

Helping Children with Autism Medicare Plan

Better Start for Children with Disability

Allied Health Services For Indigenous Australians Who Have Had A Health Check

Referral Name*

Referral Provider Number*

Plan Start Date*

DD dash MM dash YYYY

Number of Sessions*

Please type your insurance provider*

Community Visits

Community visits may be beneficial at points during intervention. Parents and carers are required to remain onsite for home sessions, to maximise the value of the sessions and transference of therapeutic recommendations. Please fill out the following information to prepare our team members appropriately.

Is there adequate on street parking close to the home?*

Are there any restrictions on the parking areas around home?*

Do you have pets? (Please ensure all pets are outside of therapy room or restrained)*

Is there adequate mobile reception?*

Is the room clean and free of clutter?*

Is the room adequately heated/cooled?*

Is the room well ventilated?*

Is working area adequately lit?*

Is there adequate seating and desks space available?*

Is there adequate space available for gross motor interventions?*

Are there smokers in the house? (Please refrain from smoking during the session)*

Has any aggression from the client / other occupants been reported?*

Does the client / other occupants have a psychiatric history?*

Does the client /other occupants have a history of alcohol or drug misuse?*

Is the behaviour of other adult/ family members felt to be appropriate?*

Does the client / other occupants smoke within the home?*

Are there any firearms on the property?*

Any comments?

Posity reserve the right to deny community visits and treatment sessions should there pose a risk to our staff.

Behaviours of Concern

At times when participants are upset/ frustrated/ or unable to communicate their needs, they can exhibit behaviours of concern. Please be as honest as possible as this helps our therapist to prepare for successful and engaging sessions.

Does the participant have a current Behaviour Support Plan or is awaiting a Behaviour Support Plan?*

Yes

What is the details of the Behaviour Support Practitioner?*

Please upload the Behaviour Support Plan*

Max. file size: 512 MB.

Any behaviours of concern?*

At times when some participants are upset/ frustrated/ or unable to communicate their needs, they can exhibit behaviours of concern. Identifying these behaviours of concerns will help our therapist to help the participant better. Please tick any behaviour of concern that you can identify.

Biting (self or others)

Hitting

Smacking

Hair pulling

Kicking (objects or others)

Strangling

Forceful pushing

Head butting

Verbal aggression

Eye gouging

Spitting

Other behaviours

None

Other (please elaborate)

Has any aggression from the client / other occupants been reported?*

Does the participant have any mental health diagnoses or history of psychosis?*

Mental illness such as Schizophrenia, Depression, Anxiety, OCD, PTSD, Bipolar Disorder, Dissociative Disorder, Personality Disorder, Eating Disorder, episode of psychosis.

Does the participant use any regular medications? Are they compliant with taking their medication / Do they need assistance with taking their medication? Are there any instances of psychosis?*

Another adult must be present during any home visits. Please confirm there is a caregiver, relative or support worker who is available to attend should a home visit be required.*

Please specify the care giver, relative or support worker who will attend the visit*

Has there been any history of physical or psychological violence or threats of violence towards others?*

Any trigger(s) for the above behaviours of concern? (If applicable)

Triggers can include mention of specific words, phrases, a particular toy or action. Please list in as much detail as possible:

How did you hear about us?

How did you hear about us?*

Google search

Facebook/Instagram/LinkedIn

Family / Friend

Support Coordinator

Allied Health Practitioner

Plan Manager

Kismet

Karista

Clickability

myCareSpace

Kinora

Yellow Pages

Other

MyCareSpace Referral Reference Number

Support Coordinator Name

Company Name

Practitioner Name

Company Name

GP Name

Clinic Name

Company Name

Please provide website address

Please upload any relevant documents (if available & required)

Drop files here or

Max. file size: 512 MB.

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