Person filling out this form

First name *

Surname (Last Name) *

Date of birth *

Email Address *

Home phone or Mobile *

What is your preferred method of communication? *

Current home address *

How did you find out about us? *

Are you a parent or carer? *

Is this intake form for yourself or someone you care for eg child?

MyselfMy child (or person I care for)

Are you an NDIS participant? *

NDIS number #

Are you Self / Plan / NDIA Agency managed?

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you

Work Information

Occupation

Do you volunteer? If so, describe your role

Health Information

Doctor *

Please list any medications you are currently taking

Medications

Dose

Please list any allergies

Allergy

Severity

Diagnosis and conditions

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Diagnosis 6

Are you currently seeing a psychologist or counsellor for any of the above diagnosis? *

YesNo

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Do you currently engage in any exercise or physical activity? If so, please describe the activity and frequency eg daily/weekly/when ever I feel like it

How would describe your relationship with food / diet?

I eat a variety of foodsI have a strict diet eg GF, vegetarian, veganI struggle with eatingI only eat when I am forced to/required toI eat a small range of foods eg only white foods

Please upload any medical reports/diagnostic reports here

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What is/are the main reason/s for reaching out to the Mandurah Neurodiversity Centre? *

Consent

I confirm that above information I have provided is true, complete and accurate. *

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Date *