Psychcentral NDIS Intake - Allied Health Services Form

Once you have completed this form an NDIS intake officer will be in contact within 3 working days to organise services.

Psychcentral

ABN: 12101 099 521

Contact us : 1300 856 779

Email us: Ndis@psychcentral.com.au

Participant Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Street Address *

City *

State *

Postcode *

Background Information

Please Specify Your Gender *

MaleFemalePrefer not to sayOther

Other

Religious and /or cultural identities of personal importance *

Preferred Method and Mode of Communication *

Verbal CommunicationWritten CommunicationVisual CommunicationAuditory Communication

Are you Aboriginal or Torres Strait Islander? *

YesNo

Do you Require an Interpreter? *

Yes No

Please State Language (If Applicable)

Emergency and Disaster Management

In Case of an Emergency or Disaster Who Is Part of Your Support Network (Please Provide Name , Relationship and Contact Details) *

In Case of an Emergency or Disaster Do You Have an Alternative Place To Stay ( Yes or No and if so with whom ) *

In Case of an Emergency or Disaster , Please Provide the Details of your GP, Chemist and Local Hospital *

Please List any Medication or Assistive Equipment you Currently Use (e.g wheelchair or iPad to communicate)

In Case of an Emergency or Disaster Do you Have Any Pets and How Do You Plan To Manage Them ( Please Provide Name and Breed )

Participant Representative Details (If Applicable) & Emergency Contact

First Name

Last Name

Representative's Relationship

Phone Number

Email

Street Address

City

State

Postcode

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Number *

Emergency Contact Relationship *

Referrer / Support Coordinator Details (Person Making the Referral)

First Name *

Last Name *

Agency

Role

Email Address *

Phone Number *

I have obtained consent from the participant to make this referral and provide Psychcentral with the participant's personal and medical details. *

Reason For Referral

Preferred Location For Services *

Who Should Psychcentral Contact To Arrange The Initial Consultation *

Preferred Day or Time for Scheduled Appointments

Preferred Appointment Frequency

WeeklyFortnightlyMonthly

Therapist Preferences (i.e, Male/female, Language)

Reason For Referral/Relevant Medical Information *Any health, medication, disability, environmental, safety risk, emotional/behavioural, cognitive/developmental, mobility, nutrition or dietary conditions relevant to the participant’s care. Where possible, obtain management plans for these conditions (e.g. health plan, behaviour management plan, epilepsy plan, asthma plan, allergy plan).

Please List Relevant Disability, Health and Medical Conditions *

Please Provide Any Supporting Medical or Allied Health Documentation Related To The Participant

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NDIS Details

NDIS Number *

Plan start Date *

Plan Review Date *

How are you Managed under your Current NDIS Plan? *

NDIA-ManagedPlan-Managed Self-Managed

Plan Manager Agency (If Applicable)

Plan Manager Agency Contact Number (If Applicable)

Plan Manager Email Address (If Applicable )

Available Funding Budget *

How Many Hours of Funding From The Category Chosen Will Be Allocated For PsychCentral’s use (Please Provide a Funding Allocation Breakdown)? *

Client Goals (As stated in the NDIS plan) or Provide a Copy or Screenshot (Please Be Advised We Are Unable To Procced With This Intake Unless The NDIS Plan Goals are Provided ) *

File Upload (Please attach a copy of the current NDIS plan if possible)

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Other Details

Does the Participant Have Difficulty Swallowing Food or Fluids? (If ticked yes , we will contact you to assist in making a referral to the required clinicians or service ) *

YesNo

Known Allergies

Does the Participant Have a Criminal Record, Spent Time in Prison or in a Forensic Hospital, Shown Aggressive or Challenging Behaviour? Are there any Behaviours of Concern Present? Describe Types

Does the Participant Have a Current Behaviour Management Plan in Place?

YesNo

Does the Participant Require a Behaviour Management Plan

YesNo

Is the Participant Verbal

YesNo

Further Information or Details Related to the Participant

Date Completed *

Signature

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Internal Staff Use Only

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Disclaimer: Services will only be organised once the service agreement has been signed.

Any request for NDS review reports require 4-6 weeks notice.

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V1. 22-11-21