Client Intake Form

Client Details

Name: *

Date Of Birth: *

Gender: *

Address: *

Email Address:

Phone number:

Person to contact to make appointments

Name: *

Phone:

Email:

Person responsible for signing documents (if applicable)

Name:

Phone:

Email:

Emergency contact

Name: *

Phone: *

Referrer

Name: *

Organisation: *

Phone:

Email:

Coordinator of supports / Case Manager (if not referrer)

Name:

Organisation:

Phone:

Email:

General Practitioner details

Name: *

Phone: *

Address: *

Medical Specialist details

Neurologist:

Yes

Rehabilitation Medicine Specialist:

Yes

ENT:

Yes

Referral details

Reason for referral: *

Diagnosis: *

Service(s) required

Please select: *

Rehabilitation Medicine SpecialistSpeech PathologyExercise PhysiologyPhysiotherapyOccupational TherapyTherapy Aide (in addition to other Neuro Alliance Therapy Service)HydrotherapyUpper Limb Assessment And TreatmentMultidisciplinary Tone ClinicNeuromuscular Orthotist

Reasons for Speech Pathology – please indicate all that apply:
CommunicationSwallowingMealtime Management Plan

Communication Problems – please indicate all that apply:
SpeechVoiceLanguageLanguageCognition

Priority Areas – does the participant:
Have concerns regarding their swallowing (recent aspiration)?Have an urgent need for a communication system?Have an increased risk of losing their independence due to poor communication?

Location Of Services (tick all that apply):
Neuro Alliance Gym/PoolClient HomeCommunity Gym/Pool - Please Specify

Reasons for Physiotherapy – please indicate all that apply:
General PT Assessment (for exercise program, equipment prescription) – please indicate below in location whether centre based or community appointments are requiredMobility review (including client specific manual handling training and protocols)Assessment for hydrotherapy

General PT Assessment Report Required?
YesNo

Priority Areas – does the participant:
Recent fall or a change in their function or mobilityRecent diagnosis or discharge from hospitalHave a high risk of hospitalisation or injury without PT support

Reason for Occupational Therapy – please indicate all that apply:
General OT Assessment (e.g review of activities of daily living (ADL), equipment or home modifications)Functional Capacity Assessment – includes report (e.g funding disputes / identifying care needs)Manual Handling Review (training development and protocols)

General OT Assessment Report Required?
YesNo

Priority Areas – does the participant:
Have a current pressure injury (bed sores/ulcers)Have equipment which is deemed dangerous or ill fittingRequire significant physical support to transfer e.g out of bed/chairHave a high risk of hospitalisation or injury without OT support

What are your preferred Days for appointments?: *

MondayTuesdayWednesdayThursdayFriday

What is your preferred Time of Day?: *

AMPM

Preferred Location of appointments (please select all that apply):

Neuro Alliance ClinicHome VisitsOther: Please specify

Funding source

Please select: *

iCareCommunity Care PackageNDISOther

Please advise how many hours are available for service/s requested: *

Client number (NDIS, iCare, other):

NDIS plan start and finish dates:

NDIS funds management:

Self-managedPlan ManagedNDIS Managed

NDIS Plan Manager details:

NDIS Goals (please list goals on plan or provide copy of plan if available):

Please attach any other relevant documents:

NDIS planiCare myPLanDischarge summariesSpecialist reports
NDIS plan file:
iCare myPLan file:
Discharge summaries file:
Specialist reports file:

Are there any relevant behavioural issues:

NoYes: Please specify

Attach behavioural support plan if available:

Are there any safety concerns or special considerations at place of residence (please note Neuro Alliance may require a home visit risk assessment to be completed):

NoYes: Please specify

You will receive acknowledgement of referral being received within 5 business days.