Participant: NDIS/NDIA number*

Participant: first name*

Participant: Surname*

Participant: Preferred first name*

Email address*

Phone number*

Date of birth*

Residential address*

Suburb/ Town*

State*

Postcode*

Preferred method of communicationSelect an answerEmailPostSMSPhone

Attach NDIS Plan (or relevant section of the plan)

If plan management provider, who is the provider?

Marital statusSelect an answerSingleIn a relationshipMarriedWidowedDivorcedSeparatedOther

Participant living situationSelect an answerOwn home/ living aloneOwn home/ living with familyLiving in supported accommodationHomelessTemporary (living with friends, family or other accom)At risk (e.g. evictions, behind in rent, family violence)Other

Is the participant of aboriginal or torres strait islander descent?Select an answerYesNoUnknown

Does the participant have a current behavioural support plan?Select an answerYesNo

If other, please describe

Does the participant have a current behavioural support plan?
If yes, please attach the behavioural support plan

Cognition detailsSelect an answerVery GoodOwnFairPoor
CommunicationSelect an answerVerbalNon verbalAidsOther
Hearing impaired interpreter required?Select an answerYesNo

Language Interpreter required?Select an answerYesNo

If other, which languages?

Is the participant of culturally and linguistically diverse background?Select an answerYesNo

If other, please describe

Formal diagnosis - primary

Formal diagnosis - secondary

Other relevant information about the participant

Do you have any legal issues that may affect services?Select an answerYesNo(E.G. APPREHENDED VIOLENCE ORDER AVO)

Preferred start date
How did you hear about Comfort Support?Select an answerSupport CoordinatorFriend or FamilyGoogleOnline AdsFacebookPrint Media (Comfort Support Brochures, Newspapers etc.)Other
If other, please describe