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/they an NDIS participant? *

NDIS number #

Are you/they Self / Plan / NDIA Agency managed?

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you

THE FOLLOWING QUESTIONS ARE FOR THE PERSON NEEDING SUPPORT

Work Information

Occupation

Do you volunteer? If so, describe your role

Health Information

Doctor *

Please list any medications you / your child is currently taking

Medications

Dose

Please list any allergies

Allergy

Severity

Diagnosis or Conditions

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Diagnosis 6

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

YesNo

Do you smoke?

YesNoI used to smokeN/A (Child)

Do you use recreational drugs?

NoI have previously usedI currently useN/A (Child)

Do you / your child 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 you / your child's 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 Mandurah ND Centre? *

Consent

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

Signature *

Clear

Date *