PARTICIPANT INTAKE

A pathway to support.

Start your journey with Ebenezer Mission. Tell us about your goals and support needs, review your details and submit them to our team.

COMPLETE ONLINE

Intake Form

Your intake form is sent to our staff-only website inbox. Please have the participant’s consent before sharing their information.

Fields marked * are required. Optional questions can be left blank. Include only information relevant to this intake form.

01 Participant details

Participant full name *

Date of birth

Age at intake (calculated)

Participant address

Participant phone

Participant email

Preferred language

02 Person completing this form

Your full name *

Relationship to participant *

Your email *

Your phone

Preferred contact method

03 Services and funding

Service you are interested in *

Funding arrangement

NDIS participant number (optional)

Plan start date

Plan end date

Plan manager / support coordinator contact (optional)

04 Disability, health and access needs

Disability / diagnosis (if known)

Disability level / support needs as recordedUse the wording in an existing assessment or support plan, if available. There is no single level scale for all disabilities.

Daily support needsFor example: communication, mobility, personal care, eating, supervision or sensory needs.

Any known allergies?

Allergies and relevant reactionsInclude food, medication or environmental allergies that staff need to know about.

Allergy / anaphylaxis action plan available?

Other health or safety information relevant to supportFor example: seizures, swallowing risks, dietary needs or an existing emergency plan. Staff will discuss care arrangements with you.

05 Behaviour and positive behaviour support

Are there behaviours that may create a safety risk?

Behaviours of concern and safety risksDescribe what happens, how often and any recent concerns, such as physical aggression, harm to self or others, leaving a safe area or property damage.

Known triggers and early warning signs

What helps the participant feel safe and supported?Include communication preferences, calming strategies and approaches that help or should be avoided.

Is there a Behaviour Support Plan (BSP)?

Behaviour support practitioner / provider contact

BSP review date (if known)

Can a copy of the BSP be provided to our team?

Does the existing plan identify regulated restrictive practices?Record existing plan information only. Our team will review the plan and required arrangements before any service delivery.

06 Goals and support

What would you like support with? *

Goals and desired outcomes

Strengths, interests and preferences

Current supports and relevant access needs

Preferred days / times

07 Emergency contact and consent

Emergency contact name (optional)

Relationship to participant

Emergency contact phone

Declaration — type your full name *

Declaration date *

Typing your name records your declaration. It does not create a handwritten signature.